Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Chemotherapy Drugs on August 3, 2021 
 
You asked the Plan to waive the coinsurance for Chemotherapy Drugs. You say that you do not have money 
for this. The Plan denied your request. The Plan says the 20% coinsurance you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Chemotherapy Drugs. The allowed amount of the injection is $3,774.36, resulting in a 
coinsurance amount of $754.88. 
 
You have been asked to pay 20% coinsurance for Chemotherapy Drugs. Chemotherapy Drugs fall within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
Chemotherapy Drugs on August 3, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hearing test (92557) provided on 
September 29, 2021. 
 
You asked the Plan to waive the copayment for the hearing test. You say that the services should be covered. 
The Plan denied your request. The Plan says the costsharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for Hearing services.  
 
 
  You have been asked to pay a $15 copayment for a hearing test. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a hearing test (92557) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on October 
20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that since the member was in a nursing 
facility, the doctor was not responsible to get authorization. You also say the nursing home was responsible to 
obtain prior authorization for their patients. The Plan denied your request. The Plan says an authorization was 
not obtained prior to the services being rendered, and the provider is not participating with the Plan. The Plan 
also says that it was determined the services were not urgent or emergent in nature. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided 
on October 20, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the single eyeglass lens, trifocal eyeglass lens and anti-reflective lens coating, provided on November 8, 2021.
You asked the Plan to pay for the eyewear. You say that the items should be covered. The Plan denied your request. The Plan says you exceeded the Plan's maximum allowed benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with $150 allowance every two years. We looked at the file and the Plan's rules. You exceeded the Plan's maximum allowance for eyewear and are responsible for the difference. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the single eyeglass lens, trifocal eyeglass lens and anti-reflective lens coating, provided on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on July 26, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that you had no advance notice of receiving the 
specimen and were unable to obtain prior authorization. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to 
pay for genetic testing provided on July 26, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasties in conjunction with extractions (D7310 
x2 and D7311 x2) and simple extractions (D7140 x12) provided on July 20, 2021. 
 
You asked the Plan to pay for the alveoloplasties and simple extractions. You say that you would like to recoup 
the $900.00 you spent out of pocket, and if possible, the $262 as well. The Plan denied your request. The Plan 
says the alveoloplasties are not covered benefits under your dental plan. The Plan also says that your benefits 
for the simple extractions have been satisfied and the frequency limitation has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the alveoloplasties in conjunction with 
extractions (D7310 and D7311) are not among those covered under this benefit. The contract says that 
extractions are limited to two procedure codes per calendar year. The record shows that you received 14 simple 
extractions (D7140 x14) on July 20, 2021, two of which were covered by the Plan, and your extractions benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pay for the alveoloplasties in 
conjunction with extractions (D7310 x2 and D7311 x2) and simple extractions (D7140 x12) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the out of network cost share for the prophylaxis (D1110 x 2), 
complete series x-ray (D0210), and fluoride varnish (D1208) provided from April 5, 2021, to April 6, 2021. 
 
You asked the Plan to waive the out of network cost share for the dental services. You say that you were 
charged for 2 prophylaxis 2 days in a row. You say that you were not told you were being charged for 2. You also say that you have paid all of the bills you received. The Plan denied your request. The Plan says that 
out of network providers may bill you for any amount greater than what the plan pays the provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
out of network providers may bill you for any amount greater than what the plan pays. Additionally, fluoride 
varnish is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
waive the out of network cost share for the prophylaxis (D1110 x 2), complete series x-ray (D0210), and 
fluoride varnish (D1208) provided from April 5, 2021, to April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery (66984) rendered by the out-of-network 
(OON) provider on April 7, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the cataract surgery (66984) rendered by the out-of-network (OON) provider on  
April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Sanexas therapy, vasopneumatic device therapy, and 
subcuteneous injections of nutripharmeceuticals provided from March 29, 2021, to May 17, 2021. 
 
You asked the Plan to pay for the Sanexas therapy, vasopneumatic device therapy, and subcuteneous injections 
of nutripharmeceuticals. You say that these services were medically necessary and should be paid. The Plan 
denied your request. The Plan says these services are experimental and non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Sanexas therapy, vasopneumatic device 
therapy, and subcuteneous injections of nutripharmeceuticals. Our reviewer says that the Sanexas therapy, 
vasopneumatic device therapy, and subcuteneous injections of nutripharmeceuticals are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the requested procedures are 
considered investigational and are not eligible for coverage for the treatment of neuropathies or peripheral 
neuropathies caused by underlying systemic diseases. Regarding the vasopneumatic device therapy, the use of 
vasopneumatic devices may be considered medically necessary for the application of pressure to an extremity 
for the purpose of reducing edema. There is no documentation noting the presence of edema. This does not 
meet guidance for coverage. Regarding the subcutaneous injection of FDA Nutri Pharmaceutical blend, there is 
no applicable Medicare guidance for the provider and enrollee's geography regarding these injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Sanexas therapy, vasopneumatic device therapy, and subcuteneous 
injections of nutripharmeceuticals have not been met. Therefore, we decided that the Plan does not have to pay 
for the Sanexas therapy, vasopneumatic device therapy, and subcuteneous injections of nutripharmeceuticals 
provided from March 29, 2021, to May 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computerized tomography (CT) scan 
provided on July 21, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that since your prior colonoscopy was 
inconclusive, this CT scan should be covered. The Plan denied your request. The Plan says the copayment 
amount charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for diagnostic radiology services, such as CT scans.  
 
 
 You have been asked to pay a $325 copayment for a CT scan. CT scans fall within the Outpatient Diagnositc 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the computerized tomography (CT) scan provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the multiple treatments with the Sanexas device provided 
from November 23, 2020, through December 28, 2020, billed with codes 97112, 97032, and 97016, and the 
relate nutria-pharmaceutical injections billed with codes 96372, J3490, J3420, J3415, J3411, and J1955. 
 
You asked the Plan to pay for the Sanexas treatments with relation nutria-pharmaceutical injections. You say 
that this treatment is proven through various studies. The Plan denied your request. The Plan says this is not 
provided for a Medicare-covered indication. 
 The Plan must follow Medicare rules. Medicare rules say that therapy services can only be covered when 
provided by licensed therapists. In addition, compounded drugs must be billed with a single unit of J7999 for 
compounded drug, not otherwise classified. 
 
Review of the file shows that these services were not provided by a provider licensed to provide physical 
therapy. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. 
The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this 
compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, 
the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to 
pay for the multiple treatments with the Sanexas device provided from November 23, 2020, through December 
28, 2020, billed with codes 97112, 97032, and 97016, and the relate nutria-pharmaceutical injections billed 
with codes 96372, J3490, J3420, J3415, J3411, and J1955.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve attendant services. 
 
You asked the Plan to pre-approve attendant services. You say that this should be a covered service. The Plan 
denied your request. The Plan says attendant services such as help with personal care like bathing, grooming, 
toileting, meal preparation, and/or cleaning, are excluded from home health coverage. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of attendant services have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve attendant 
services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit and testing provided on 
October 5, 2021. 
 
You asked the Plan to waive the copayment for the office visit and testing. You say that you had the same 
procedure done last year and insurance covered it The Plan denied your request. The Plan says the copay 
applied is correct. National Emergency Declaration Covid-19 was in effect for this service last year, thus the 
copay was not applied. 
 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that enrollees must pay a 
$20 copayment for Physician/Practitioner services, including doctors office visits and a $150 copayment for 
Medicare-covered diagnostic procedures and tests other than EKG and diagnostic colorectal screenings.  
You have been asked to pay a $20 copayment for the office visit and a $150 copayment for the testing, a total 
of $170. The visit falls within the Physician/Practitioner services, including doctors office visits, and the 
testing falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the office visit and testing provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
September 16, 2021. 
 
You asked the Plan to pay for dental services. You say that these services were provided to restore health to 
your gums. The Plan denied your request. The Plan says the member has no dental benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided by an 
out-of-network provider on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services.
You asked the Plan to pre-approve the requested services. You say that you are in a lot of pain. The Plan denied 
your request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The file shows that drugs, bone graft, and alveoloplasty services were requested. Although the Plan offers a 
dental benefit in excess of Medicare coverage, the requested items or services are not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the follow-up visit provided on August 11, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the follow-up visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the follow-up visit provided on August 11, 2021, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided November 4, 2021. 
 
You asked the Plan to pay for the complete series of x-rays. You say that this was the only dentist available to 
see you. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the complete 
series of x-rays once every five years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a panoramic x-ray 
was previously covered on April 20, 2017. Based on this information, we decided that the Plan's frequency limit for coverage of the complete series of x-rays has been exceeded. Therefore, we decided that the Plan does 
not have to pay for the intraoral - complete series of radiographic images (D0210) provided November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies (S1015, S8301, A9279) provided on September 15, 2021. 
 
You asked the Plan to pay for supplies. You say that these items were supplied at your own cost. The Plan 
denied your request. The Plan says these items were not billed with valid codes. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes S1015, S8301, and A9279 are not supported in the medical record. Specifically, these 
codes have a status indicator of "I." Medicare uses another code for reporting of, and payment for these 
services. Based on this information, we decided that Medicare rules for coverage of supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for supplies (S1015, S8301, A9279) provided on 
September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction services provided on May 11, 2021. 
 
You asked the Plan to pay for the refraction services. You say that the benefit does not indicate a prior 
authorization was needed. The Plan denied your request. The Plan says the service is not covered.
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The file shows that the enrollee received a medical eye exam. The 
eye refraction services are only covered when provided as part of a routine eye exam. Based on this 
information, we decided that the Plan's rules for coverage of the refraction services have not been met. 
Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on May 11, 2021.