Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a manual wheelchair (E0130, E0325, K0030) provided on 
March 2, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the manual wheelchair. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 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 manual wheelchair (E0130, E0325, K0030) 
provided on March 2, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
(71260) provided on March 7, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you only had this CT scan done 
because your provider recommended it, and you were not aware of the cost of this service. The Plan denied 
your request. The Plan says this claim was processed correctly, and your copayment was assessed in 
accordance with your benefit. CT scans require a $325 copayment, but because the total approved cost of this 
service was lower than your copayment, you are being asked to pay a lesser amount. 
 
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 Medicare-covered diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $213.55 copayment for the CT scan. A CT scan falls within the Medicare-
covered diagnostic radiology services that are not ultrasounds 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 computed tomography (CT) scan (71260) provided on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2203, V2799) provided on 
February 18, 2022, by an out-of-network provider. 
 You asked the Plan to pay for the eyeglasses. You say that this provider offered a better cost for these 
eyeglasses than the network provider. The Plan denied your request. The Plan says eyeglasses are only covered 
when they are received through the Plan's specified network vision vendor. You must use the specified vendor 
to use your supplemental vision 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 eyeglasses only when they are received from a provider within the Plan's specified 
routine vision vendor network. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the required network. Based 
on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2203, V2799) provided 
on February 18, 2022, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nephrology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you need to continue your dialysis. The Plan 
denied your request. The Plan says the medical care you require can be provided by a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
nephrology services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation services. 
 
You asked the Plan to pay for the transportation services. You say that it was icy and the hospital contacted the 
ambulance because of the conditions. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the transportation services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Intravenous infusion therapy (96365, 
J1561, 96366, J1569) provided from January 24, 2022 to January 28, 2022. 
 
You asked the Plan to waive the copayment for the Intravenous infusion therapy. You say that the services 
should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the Intravenous infusion therapy ($999). Intravenous 
infusion therapy falls 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 copayment for Intravenous infusion therapy (96365, J1561, 96366, J1569) provided from January 
24, 2022 to January 28, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the mastectomy (19303) provided on January 24, 2022. 
 
You asked the Plan to pay for the mastectomy (19303). You say that the attached reports support CPT code 
19303. The Plan denied your request. The Plan says that procedure code 19303 is not supported by the medical 
records submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 19303 is mastectomy, simple, complete. 
 
We asked our coder 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 mastectomy (19303). Our reviewer says that the medical 
documentation supports the use of procedure code 19303. Our reviewer found that this code is used for total 
removal of breast while the pectoralis major and minor muscles and axillary nodes are left in place. This 
provider performed total right and left skin-sparing mastectomies with biopsies of right and left axillary 
sentinel lymph nodes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the mastectomy (19303) have been met. Therefore, we decided that the Plan has 
to pay for the mastectomy (19303) provided on January 24, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on March 21, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you never had to pay a specialist 
copayment and wish they would place the right code they normally use. The Plan denied your request. The 
Plan says the cost-sharing 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 a $45 
copayment for each Medicare-covered visit with a specialist. Covered services include consultation, diagnosis, 
and treatment by a specialist. 
 
You have been asked to pay a $45 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's office visits 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 office visit on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 25, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on October 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethasone. 
 
You asked the Plan to pre-approve Dexamethasone. The Plan denied your request. The Plan says this drug is 
not covered under the medical benefit for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexamethasone.  
 
 
 Benefits for Dexamethasone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 8, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you should not have a 
copayment for this visit. The Plan denied your request. The Plan says the copayment applied was 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 $50 
copayment for urgently needed services.  
 
You have been asked to pay the allowed amount of $27.23, which is less than the $50 copayment for an urgent 
care visit. An urgent care visit falls within the Urgently Needed Services 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 an urgent care visit provided on January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on March 
22, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you did not know that follow-
up visits had a copayment. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $35 
copayment for each specialist visit.  
 
You have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 a specialist office visit provided on March 22, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from February 11, 2022, to February 
15, 2022. 
 
You asked the Plan to pay for inpatient care. You say that these services were all care for an accident that 
occurred while you were travelling and no in-network providers were available. The Plan denied your request. 
The Plan says that the denial of payment for this service is correct, because this provider is out-of-network with 
the Plan and authorization was not obtained. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective 
medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson 
with an average knowledge of medicine would reasonably expect the absence of immediate medical attention 
would result in serious jeopardy to their health. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. You say that this was needed due to an accident that occurred while you were 
travelling. The Plan says that this provider is out-of-network with the Plan and authorization was not obtained. 
The Plan did not submit any medical records or attempts to obtain medical records. Without supporting 
records, we cannot determine whether your medical care was urgent or emergent in nature. Therefore, the Plan 
has not shown that its decision to deny payment for these services is medically justified or correct according to 
Medicare rules. Therefore, we decided that the Plan has to pay for inpatient hospital care provided from 
February 11, 2022, to February 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycontin. 
 
You asked the Plan to pre-approve Oxycontin. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycontin.  
 
 
 Benefits for Oxycontin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for the contact lenses (S0500) provided on March 8, 
2022. 
 
You asked the Plan to pay the full cost for contact lenses. You say that these services should be covered in full 
as they are medically necessary. The Plan denied your request. The Plan says the contacts are covered, and 
your benefits were applied in accordance with your contract. The total cost of the contact lenses was $180. 
Your benefit covers a maximum of $150 per calendar year for eyewear. You are responsible for any remaining 
cost. 
 
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 up to $150 per calendar year when they are received from a provider 
within the specified vendor network. You will pay any cost over the allowed charge. 
 
We looked at the file and the Plan's rules. The record shows that the original cost of the contacts was $180. The 
contacts were received from a network provider, and the Plan has paid the full $150 allowance. You are being 
asked to pay the remaining $30 charge which exceeds this allowance. This means you have been asked to pay 
the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to 
pay the full cost for the contact lenses (S0500) provided on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye examination to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve eye exam. You say that you went to your optometrist that you have been 
seeing for 30 years and were advised to see an ophthalmologist. The Plan denied your request. The Plan says 
the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and 
you can be treated by an in-network specialist. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an eye examination to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) and bitewings (D0274), provided by an 
out-of-network provider on April 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that this provider was not in-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for prophylaxis (D1110) and bitewings (D0274), provided by an out-of-network provider on April 4, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal facet joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve thermal facet joint RFA. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one 
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 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 pre-approve thermal facet joint RFA. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is insufficient 
documentation to support this procedure. Therefore, at this time, the request is deemed medically unreasonable 
and unnecessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal facet joint RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal facet joint radiofrequency ablation (RFA).