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

 
We decided that the Plan does not have to waive the coinsurance for the Gammagard injection you received on 
November 4, 2021. 
 
You asked the Plan to waive the coinsurance for the Gammagard injection. You say that you do not believe you 
owe this amount. The Plan denied your request. The Plan says you were charged this coinsurance 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 15% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 15% coinsurance for the Gammagard injection. The Gammagard injection falls 
within the Medicare Part B 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 
the Gammagard injection you received on November 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid tablet. 
 
You asked the Plan to pre-approve Synthroid tablet. You say that this drug is medically reasonable and 
necessary. The Plan denied your request. The Plan says this drug is not covered under the medical 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 Synthroid tablet.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307, 82542, 84228, G0480) 
rendered by the out-of-network (OON) provider on November 1, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (80307, 82542, 84228, G0480) rendered by the out-of-
network (OON) provider on November 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan of the extracranial arteries 
you received on May 5, 2021. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that the copayment is high for the 
cost of the procedure.  You believe that the cost share should be much less. The Plan denied your request. The 
Plan says you were charged this copayment 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 $160 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $160 copayment for the duplex scan. The duplex scan falls within the 
radiological diagnostic 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 
the duplex scan of the extracranial arteries you received on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a panoramic radiographic 
image (D0330), and periapical imaging (D0220 and D0230) provided by a participating provider on November 
11, 2021. 
 
You asked the Plan to pay for a limited oral evaluation, a panoramic radiographic image, and periapical 
imaging. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the 
rendered dental services are not covered 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. 
 
Though 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 pay for a limited oral evaluation (D0140), a panoramic radiographic image (D0330), and periapical imaging (D0220 and D0230) 
provided by a participating provider on November 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the scanning computerized ophthalmic 
diagnostic imaging (SCODI) test you received on October 7, 2021. 
 
You asked the Plan to waive the copayment for the SCODI test. You say that insurance should have taken care 
of this bill. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan 
says that because the allowed amount for the SCODI test ($36.36) is less than your copayment obligation, you 
are responsible for the full allowed amount for this service. 
 
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 diagnostic procedures and tests in a doctor's office.  
 
You have been asked to pay a $100 copayment for the SCODI test. The SCODI test falls within the diagnostic procedures and tests in a doctor'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 the scanning computerized ophthalmic diagnostic imaging (SCODI) test you received on October 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (80307, G0482) rendered by the 
out-of-network (OON) provider on October 25, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services.  Therefore, we decided that the Plan does not have to pay for the drug testing services (80307, G0482) rendered 
by the out-of-network (OON) provider on October 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the criteria for coverage of the LDCT screening have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that in this case the medical records indicate that the enrollee quit smoking about 40 years ago. For the requested LDCT scan to be covered, the enrollee must be a 
current smoker or a former smoker who quit within the last 15 years. Therefore, we decided that the Plan does 
not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on September 29, 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 office visit (99214) rendered by the out-of-network (OON) provider on  
September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (80307, G0482) rendered by the 
out-of-network (OON) provider on November 15, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services.  Therefore, we decided that the Plan does not have to pay for the drug testing services (80307, G0482) rendered 
by the out-of-network (OON) provider on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scanning computerized ophthalmic diagnostic imaging 
(92134) and an eye exam (92004) provided on June 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for scanning computerized ophthalmic diagnostic imaging and an eye exam. You 
say that you are in network with the Plan. The Plan denied your request. The Plan says the facility did not 
obtain prior authorization and there is no referral letter. The Plan also says that there are in-network providers 
available, and this provider is non-contracted with the Plan. 
 
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 scanning computerized ophthalmic diagnostic 
imaging (92134) and an eye exam (92004) provided on June 9, 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 limited oral evaluation - problem focused (D0140) 
provided September 1, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you need this service for a dental issue. The 
Plan denied your request. The Plan says this service is not covered under your 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. 
 
Though 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 pay for the 
limited oral evaluation - problem focused (D0140) provided September 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies for external drug infusion pump 
(A4222), and milrinone lactate injection (J2260) provided on from September 23, 2021, to September 30, 2021. 
 
You asked the Plan to pay for infusion therapy services. You say that the services were medically necessary. 
You also say that the enrollee was not enrolled in hospice on the dates of service. The Plan denied your request. 
The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for coverage 
of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the infusion supplies for external drug infusion pump 
(A4222), and milrinone lactate injection (J2260) provided on from September 23, 2021, to September 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from March 17, 2021, to April 9, 2021. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you were not aware that the 
enrollee was receiving SNF services. You said that the facility did not tell you where your wife was and did not 
allow you to visit. The Plan denied your request. The Plan says this copayment 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 $20 copayment per day for days 1-20, and a $100 copayment per day for days 21-44 for skilled 
nursing facility services.  
 Records show that the enrollee received SNF services for 24 days.  For the first 20 days, she was charged a 
copayment of $20 per day, for a total of $400 for those days. For the remaining 4 days, she was charged a 
copayment of $100 per day, for a total of $400 for those days. The total copayment for the stay is $800, which 
is what the enrollee is being charged. 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 copayment for 
skilled nursing facility (SNF) services provided from March 17, 2021, to April 9, 2021.  
 
Your complaint about paying a normal nursing home fee to another facility is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical osteogenesis stimulator (E0748). 
 
You asked the Plan to pre-approve an electrical osteogenesis stimulator. You say that this is medically 
necessary for your condition to help your healing post surgery. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for failed 
fusion surgery where a minimum of 9 months has elapsed since the last surgery. 
 
We looked at the file and Medicare rules. In this case, you have had a spinal fusion surgery on March 15. 9 
months have not passed since you received this surgery as required by Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of an electrical osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical osteogenesis stimulator 
(E0748).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Belsomra 5 mg tablet. 
 
You asked the Plan to pre-approve Belsomra. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
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 Belsomra 5 mg tablet.  
 Benefits for Belsomra 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve medial branch blocks. You say that the requested medial branch blocks are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested medial branch blocks. 
 
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 medial branch blocks. Our reviewer says that the enrollee does not meet criteria for the requested medial branch blocks. Our physician reviewer 
found the enrollee has another probable pain generator that has not been addressed.  Therefore, he does not 
meet the LCD criteria and the request, at this point, is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medial branch blocks.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional days in a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve additional SNF care. You say that this care remains medically necessary. 
The Plan denied your request. The Plan says the 100-day benefit limit for SNF care has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from November 19, 2021 to 
March 9, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve additional days in a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (62323). 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that it is necessary to receive 
this service immediately due to your pain. The Plan denied your request. The Plan says the benefit for epidural 
steroid injections have been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are limited to a 
maximum of four (4) sessions per spinal region in a rolling twelve (12) month period. 
 
We looked at the file and Medicare rules. The documentation indicates that four epidural injections have 
already been performed within a rolling twelve-month period. Based on this information, we decided that 
Medicare rules for coverage of a repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat epidural steroid injection (62323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Asmanex HFA inhaler. 
 
You asked the Plan to pre-approve Asmanex HFA inhaler. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 
medical 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 Asmanex HFA inhaler.  
 Benefits for Asmanex HFA inhaler may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.