Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92004) provided on August 
15, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that your plan says your eye exam was 
$0 for a checkup once per year. You also say that you paid a $45 copay, and would like this amount to be 
refunded. The Plan denied your request. The Plan says this cost sharing was charged correctly. The Plan also 
says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility. 
 
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 a specialists office visit under the Vision care benefit category.  
 You have been asked to pay a $45 copayment for the eye exam. The record shows that you received a medical 
eye exam for the diagnosis of Other secondary cataract, bilateral, and not a routine eye exam. This item/service 
falls within the Vision care 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 eye 
exam (92004) provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the single vision lenses (V2100), anti-reflective coating 
(V2750), polarization (V2762), and polycarbonate or equal lenses (V2784) purchased on July 6, 2022. 
 
You asked the Plan to pay for the single vision lenses, anti-reflective coating, polarization, and polycarbonate 
or equal lenses. The Plan denied your request. The Plan says payment was issued for the first eyewear 
purchased on November 4, 2021, and your benefit for the single vision lens has been exhausted. The Plan also 
says that the anti-reflective coating, polarization, and polycarbonate or equal lenses are not covered by 
Medicare or the Health Plan. 
 
 
 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 one pair of standard lenses and frames every two years. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that the Plan paid for eyewear 
purchased on November 4, 2021, and your single vision lenses (V2100) benefit was then exhausted. The 
contract also clearly states that anti-reflective coating (V2750), polarization (V2762), and polycarbonate or 
equal lenses (V2784) are not covered by the Plan. Based on this information, we decided that the Plan's rules 
for coverage of the single vision lenses, anti-reflective coating, polarization, and polycarbonate or equal lenses 
have not been met. Therefore, we decided that the Plan does not have to pay for the single vision lenses 
(V2100), anti-reflective coating (V2750), polarization (V2762), and polycarbonate or equal lenses (V2784) 
purchased on July 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Monitor test (0012M) provided on March 23, 
2022. 
 
You asked the Plan to pay for the Cxbladder Monitor test. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder Monitor test have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder Monitor test (0012M) provided on March 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the dialysis services provided on March 
08, 2022, to April 30, 2022. 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that you cannot afford the cost 
of the services. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for the dialysis services. This item/service falls within the 
services to treat kidney disease 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 
the dialysis services provided on March 08, 2022, to April 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dermatology visit provided on July 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a dermatology visit. You say that this provider is within the network, and this 
should be covered. The Plan denied your request. The Plan says this provider is out-of-network. There was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 dermatology visit 
provided on July 28, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the operating room services provided on 
August 25, 2022. 
 
You asked the Plan to waive the copayment for the operating room services. You say that your last medical 
procedure had a lower copayment The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $400 
copayment for surgery services at an outpatient hospital. 
 
You have been asked to pay a $400 copayment for the operating room services. This item/service falls within 
the surgery services at an outpatient hospital 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 operating room services provided on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount for the pacemaker check provided on 
June 8, 2022. 
 
You asked the Plan to waive the cost share amount for the pacemaker check. You say that the enrollee has not 
had to pay this in the past. You say that this charge came as a surprise to them. You also say that the enrollee 
should not have to pay this. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $45 copayment for Prosthetic Services and Related Supplies.  
 
The enrollee has been asked to pay a $45 copayment for the pacemaker check. This item/service falls within 
the Prosthetic Services and Related Supplies benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the cost share amount for the pacemaker check provided on June 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro device. 
 
You asked the Plan to pre-approve a MyoPro device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 pre-approve a MyoPro device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in 
widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe 
for long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MyoPro device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility services on May 23, 
2022, to June 2, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $0 
copayment each day for days 1-5 per admission and a $20 copayment each day for days 6-20 per admission for 
skilled nursing facility services. The total cost share is $80 
 
You have been asked to pay a $0 copayment each day for days 1-5 per admission and a $20 copayment each 
day for days 6-20 per admission for skilled nursing facility services. This item/service falls within the Skilled 
Nursing Facility (SNF) Care 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 skilled 
nursing facility services on May 23, 2022, to June 2, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
November 15, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you thought the 
insurance company would cover the copayment. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
emergency care 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 emergency room services 
provided on November 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a diagnostic endoscope provided on June 
01, 2022. 
 
You asked the Plan to reduce the copayment for a diagnostic endoscope. You say that your copayment should 
only be $20 The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $100 
copayment for MEdicare-covered surgery at an outpatient hospital or ambulatory surgical center, including but 
not limited to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay a $100 copayment for a diagnostic endoscope. This item/service falls within the 
MEdicare-covered surgery at an outpatient hospital or ambulatory surgical center, including but not limited to 
hospital or other facility charges and physician or surgical charges 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 reduce the copayment for a diagnostic endoscope provided on June 01, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
June 15, 2022, to June 22, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that it was medically 
necessary for you to stay at the hospital. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 $335 
copayment per day for the first 6 days for each Medicare-covered admission to a hospital and $0 for additional 
days at a hospital. From June 15, 2022, to June 22, 2022, there was a total of a 6 day stay at the inpatient 
hospital. The total copayment for the dates of service was $2,010 ($335 copayment per day x 6 days). 
 
  You have been asked to pay a $2,010 copayment for an inpatient hospital stay. This item/service falls within 
the inpatient hospital care 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 inpatient 
hospital stay provided from June 15, 2022, to June 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) stay provided 
from May 9, 2022 to May 31, 2022. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $178 
copayment per day for days 21-100 of Skilled nursing facility (SNF) care.  
 
 
  You have been asked to pay a $534 copayment for days 21-23 of SNF care. This item/service falls within the 
Skilled nursing facility (SNF) care 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 
skilled nursing facility (SNF) stay provided from May 9, 2022 to May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J2001 billed for date of service April 14, 
2022. 
 
You asked the Plan to pay for procedure code J2001. You say that you have submitted additional medical 
records to support payment. The Plan denied your request. The Plan says payment for code J2001 is bundled 
into payment for code 20611. 
 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, we have confirmed that code J2001 
is a column II code to column I code 20611. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code J2001 billed for date of service April 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on May 19, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
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 lab testing provided on May 19, 2022, by an out-
of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and treatment - angioplasty, atherectomy, 
or stents. 
 You asked the Plan to pre-approve a consultation and treatment. 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 vascular stenting of lower extremity arteries 
performed for clinically significant occlusive vascular disease will be considered medically reasonable and 
necessary for a patient under certain circumstances. 
 
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 a consultation and treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the documentation 
does not support the medical necessity of the procedures in question. The medical record documentation 
contains numerous, often directly conflicting information. The enrollees previous office notes are not 
provided. This would be of value as the enrollee underwent angiography only days earlier however the current 
office note makes no mention of the results of this study and no mention as to why the right leg was not imaged 
if the symptoms were so severe. Additionally, there has been no recent noninvasive studies including an ankle 
brachial index (ABI) since the performance of multiple interventions on both legs over multiple dates. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a consultation and treatment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a consultation and treatment - angioplasty, atherectomy, or stents.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that 
the enrollee was treated with bilevel positive airway pressure (BiPAP) while in the hospital. The provided 
primary source documentation does not contain sufficient detailed information in the medical record to justify 
the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure support (AVAPS) capability. The plan has indicated coverage for such a device is available upon 
request. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.