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

 
We decided that the Plan does not have to waive the cost share for a complete mandibular denture (D5120) 
provided on February 11, 2022. 
 
You asked the Plan to waive the cost share for a complete denture. You say that you were not satisfied with the 
dentures. The Plan denied your request. The Plan says your annual dental maximum benefit has been met. 
 
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 this benefit includes coverage up to $2,000 for preventive and comprehensive dental services. The contract says that you are 
responsible for any amount above the benefit limit. 
 
The record shows your annual dental benefit was met during the processing of this claim. You have been asked 
to pay $343 for a complete mandibular denture. This item/service falls within the dental 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 cost share for a complete mandibular denture (D5120) 
provided on February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on April 8, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital service provided on 
June 16, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital service. You say that you do not understand 
why you should be charged as a hospital out-patient. 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 $150 
copayment for Medicare-covered outpatient hospital surgery services.  
 
You have been asked to pay $150 copayment for outpatient hospital service. This item/service falls within the 
Medicare-covered outpatient hospital surgery 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 outpatient hospital service provided on June 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drug on June 22, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drug. You say that you should not be responsible for 
this amount because you were not advised about the 20% coinsurance. 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 20% 
coinsurance of the total cost for Medicare Part B drugs and administration. Covered drugs include drugs that 
usually arent self-administered by the patient and are injected or infused while you are getting physician, 
hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of $9,673.55 and 
the allowed amount is $3,206.64. $3,206.64 x 20% = $641.33. Therefore, results in the total cost sharing 
amount of $641.33. 
 
 
 You have been asked to pay a 20% coinsurance for Part B drug. This item/service 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 coinsurance for Part B drug 
on June 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
May 19, 2022. 
 
You asked the Plan to waive the copayment for an EKG. You say that you should not have a copayment for 
this service as it was done the same day as another appointment. 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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $50 copayment for an EKG. This item/service 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 an electrocardiogram (EKG) provided on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician/practitioner service provide on 
June 27, 2022. 
 
You asked the Plan to waive the copayment for physician/practitioner service. You say that the Plan told you 
that the provider was in-network. 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 $40 
copayment for in-network specialist's office.  
 
You have been asked to pay $40 copayment for physician/practitioner service. This item/service falls within 
the in-network specialist's office 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 
physician/practitioner service provide on June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on May 26, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you feel you should not be 
charged a 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 $30 
copayment for outpatient diagnostic tests and therapeutic services and supplies/lab services drawn or processed 
at an urgent care center or outpatient hospital or free-standing independent laboratory.  
 
You have been asked to pay a $30 copayment for laboratory services. This item/service 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 laboratory services provided on May 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy (45378) 
provided on July 22, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was a routine 
colonoscopy but was billed as a diagnostic colonoscopy. You also say that this should have been a routine 
benefit. 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 $325 
copay for Outpatient surgery.  
 
 
 
 
 You have been asked to pay a $325 copay for the diagnostic colonoscopy. This item/service falls within the 
Outpatient surgery 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 diagnostic 
colonoscopy (45378) provided on July 22, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Darzalex Faspro (J9144). 
 
You asked the Plan to pre-approve Darzalex Faspro. You say that the requested drug is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not 
been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Darzalex Faspro. Our reviewer says 
that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found 
that the Plan requires a trial of Velcade before they will approve the requested drug. The requested medication 
is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred 
step-one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an 
adverse effect from, the Plan's preferred step-one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex Faspro have not been met. Therefore, we decided that the Plan does 
not have to pre-approve treatment with Darzalex Faspro (J9144).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 30, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that you do not see patients directly and you cannot 
facilitate authorization. The Plan denied your request. The Plan says authorization was not obtained prior to 
services being rendered. The referring provider is also not 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 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 laboratory services provided on June 30, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the genetic testing services provided on May 19, 2022. 
 
You asked the Plan to pre-approve the genetic testing services. You say that you would like this claim 
reprocessed for medical necessity. The Plan denied your request. The Plan says that the claim has been billed 
with an incorrect date of service. 
 
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 case file does not show that the lab service does not meet any of the exceptions outlined in the Medicare 
ruling. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding 
their decision to deny your request. Therefore, we decided that the Plan has to pre-approve the genetic testing 
services provided on May 19, 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 Triamt/hctz. 
 
You asked the Plan to pre-approve Triamt/hctz. The Plan denied your request. The Plan says Triamt/hctz is a 
self-administered drug, and does not fall under Part B coverage. 
 
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 Triamt/hctz.  
 
Benefits for Triamt/hctz 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to be transferred to the rehabilitation 
facility in order to get the dual benefit of both medical care and rehabilitation that could be most beneficial to 
you. The Plan denied your request. The Plan says an admission to Acute Rehabilitation is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. Our physician reviewer also found that there is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network gastroenterology visit 
provided on April 08, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network gastroenterology visit. You say that you 
thought this was only a $35 copayment, not a $50 one. 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 $50 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $50 copayment for an out-of-network gastroenterology visit. This item/service 
falls within the physician/practitioner services, including doctors 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 an out-of-network gastroenterology visit provided on April 08, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 44110. We decided that the Plan does not have to pay for 47600.  
 
You asked the Plan to pay for surgical services (procedure codes 47600, 44110) provided to the enrollee on 
February 8, 2022.. You say that this should be paid for. The Plan says that the records do not support the 
services billed. 
 
We decided that the Plan has to pay for 44110.  
 
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 44110 is "Excision of 1 or more lesions of small or large 
intestine not requiring anastomosis, exteriorization, or fistulization; single enterotomy." 
 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 for CPT 44110. Our reviewer says that there is 
mention of removal of tumors of intra-abdominal origin without anastomosis along the small bowel and 
abdominal wall. This would support CPT code 44110 as care that was rendered in this case. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
44110.  
 
We also decided that the Plan does not have to pay for 47600. 
 
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 CPT 47600 is "Cholecystectomy." 
 
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 for CPT 47600 Our reviewer says that the patient 
underwent a exploratory laparotomy, splenectomy, partial colectomy, removal of implants and mesh hernia 
repair. There is no mention of CPT code 47600 which is an open cholecystectomy as there is no mention of 
removal of the gall bladder in the operative report. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 47600 have not been met. Therefore, we decided that the Plan does not have to 
pay for 47600. 
 
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 pre-approve an insertion of new or replacement of permanent 
pacemaker with transvenous electrode(s); atrial and ventricular (33208). 
 
You asked the Plan to pre-approve a pacemaker. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for a permanent pacemaker 
implantation. There was no documentation of the enrollee having symptomatic bradycardia and as a result, a 
pacemaker is not medically necessary for her. 
 
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 pacemaker. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of symptomatic bradycardia. As such, there is insufficient 
documentation to support the medical necessity for insertion of a pacemaker in the enrollees clinical 
management. 
 
 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 pacemaker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an insertion of new or replacement of permanent pacemaker with transvenous electrode(s); 
atrial and ventricular (33208).