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

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on June 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 laboratory services rendered by the out-of-network (OON) provider on  
June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance image guided high intensity 
focused ultrasound (MRgFUS). 
 
You asked the Plan to pre-approve an MRgFUS. You say that the enrollee's handwriting is beginning to 
worsen. You say that the enrollee's hand begins shaking more when she is getting up from a seated position or 
holding on to something. You say that the enrollee was initially treated with beta-blocker, but that the tremors 
worsened bilaterally and subsequently she started on Gabapentin. The Plan denied your request. The Plan says 
the enrollee does not meet the requirements for the procedure being requested. 
 
The Plan follows Medicare rules. Medicare rules say that MRgFUS is covered for certain medical indications.  
 
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 an MRgFUS. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has a medical history that 
includes medical refractory extensor tremor. The enrollee shows to be most bothered by her right-hand tremor, 
which is her dominant hand, but has tremors on both sides. The enrollee is noticing her handwriting is 
beginning to worsen and she shakes more when getting up from seated position or holding onto something. The 
enrollee is currently on Gabapentin and Metoprolol, which have been somewhat helpful. The enrollee watched 
her mother progress with refractory extensor tremor and the recollection is traumatic for her. The enrollee's 
tremor is both head-nodding and upper extremities. Magnetic resonance imaging (MRI) of the Brain done on 
April 30, 2021, showed small gliotic basal lateral right occipital temporal encephalocele and associated right 
transverse arachnoid granulation; also, persistent partially empty appearance of the sella. To qualify for 
coverage of MRgFUS, the enrollee's tremor must be moderate to severe in symptoms in the dominant hand or 
causes significant disability and the records must show that the enrollee has not responded to at least two kinds 
of medications. The enrollee is also required to not be a surgical candidate for Deep Brain Stimulation. The 
records sent to us fail to show why the enrollee is not a candidate for Deep Brain Stimulation - which is a non-
destructive treatment for essential tremor. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRgFUS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance image guided high intensity focused ultrasound (MRgFUS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation (office visit) for cell therapy (the 
transplantation of human cells to replace or repair damaged tissue and/or cells) (CPT code(s): 99205, 99215) to 
be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the stem cell transplant will help 
with improving your quality of life as you are paraplegic. The Plan denied your request. The Plan says this 
provider is not a Plan contracted provider. The Plan states the notes do not show that you have an existing 
relationship with the out-of-network provider. The Plan states your notes do not show that the out-of-network 
provider is willing to contract with the Health Plan, so this request has been denied. 
 
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 
consultation (office visit) for cell therapy (the transplantation of human cells to replace or repair damaged 
tissue and/or cells) (CPT code(s): 99205, 99215) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician services provided to the enrollee on May 10, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says that the enrollee did not have prior authorization for out of network care.

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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plans denial is based on the 2021 Evidence of Coverage. However, the Plan sent a copy of the 2020 Evidence of Coverage. The Plan has not provided the correct contract and therefore has not substantiated its denial. Therefore, we decided that the Plan has to pay for physician services provided to the enrollee on May 10, 2021.

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 deductible for dermatology services you received on April 
7, 2021. 
 
You asked the Plan to waive the deductible for the dermatology services. You say that you have never had to 
pay more than $10 for these services in the past. The Plan denied your request. The Plan says you had not yet 
met your deductible at the time of these services.  You were charged the remaining $288.73 left on your 
deductible correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to specialist services.  
 
The dermatology services you had fall within the benefit category for specialist services. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to specialist 
services. This cost sharing is a contractual obligation that had not been met at the time the dermatology services 
was received on April 7, 2021. Therefore, we decided that the Plan does not have to waive the deductible for 
dermatology services you received on April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your intention is to avoid surgery and lessen the 
extreme pain. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation received on July 14, 2021. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you feel these services should be 
covered because you received a chipped tooth while vacationing. The Plan denied your request. The Plan says 
you exceeded your benefit limit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the limited 
oral evaluation when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Review of the file shows that the Plan covers one limited oral 
evaluation per plan year. You previously received a limited oral evaluation on January 28, 2021 which was 
processed and paid by the Plan. This means you exceeded your benefit limit for this service. Based on this 
information, we decided that the Plan's rules for coverage of the limited oral evaluation have not been met. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation received on July 14, 
2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit and diagnostic radiology 
services provided on January 23, 2021, and January 24, 2021. 
 
You asked the Plan to pay for an emergency department visit and diagnostic radiology services. You say that 
the enrollee's hospice coverage was revoked on January 4, 2021, and Medicare will only pay up to  
January 4, 2021. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the member?s terminal condition. The 
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers 
attending physician services and all care unrelated to the terminal illness until the first day of the month 
following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 4, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for an emergency 
department visit and diagnostic radiology services provided on January 23, 2021, and January 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit you had with a gynecologist 
on April 16, 2021. 
 
You asked the Plan to waive the copayment for the gynecology visit. You say that this was your Annual Well-
Woman exam and that it is covered 100%. The Plan denied your request. The Plan says you were charged this 
copayment correctly.  The Plan says that they contacted the provider and the provider confirmed that you did 
not have an annual wellness visit.  The provider confirmed that you had a regular office visit for a medical 
issue. 
 
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 visits with a specialist.  
 You have been asked to pay a $30 copayment for the gynecology visit. The billing records show that you were 
evaluated for postmenopausal atrophic vaginitis, not for a well woman exam. That is why the gynecology visit 
falls within the visits with a specialist benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the office visit you had with a gynecologist on April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walking boot you received on February 23, 2021.

You asked the Plan to waive the coinsurance for the walking boot. You say that you feel as though the provider is overcharging for this item. 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 20% coinsurance for durable medical equipment. 

You have been asked to pay 20% coinsurance for the walking boot. The walking boot falls within the durable medical equipment. benefit category. We confirmed that the Medicare-allowed rate for the walking boot you received is $259.89, so your 20% coinsurance equals $51.98. This is the amount you are being charged. 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 walking boot you received on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiovascular procedure provided on 
May 17, 2021. 
 
You asked the Plan to waive the copayment for a cardiovascular procedure. You say that you were admitted to 
the hospital for your heart condition. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 $100 
copayment for outpatient procedures and services provided in an outpatient hospital facility. 
 
You received a cardiovascular procedure at an outpatient hospital facility on May 17, 2021. Therefore, you are responsible to pay the $100 copayment.   
 
You have been asked to pay a $100 copayment for a cardiovascular procedure. A cardiovascular procedure 
falls within the outpatient hospital 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 a cardiovascular procedure provided on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 24, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network physician services provided on 
May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the lab services you received from an out-
of-network hospital on May 7, 2021. 
 
You asked the Plan to waive the deductible for the lab services. You say that this facility is in-network.  You 
stated that your husband went to this same facility and his claim was considered in-network. The Plan denied 
your request. The Plan says you had not met your deductible, so this cost sharing was charged correctly. The 
Plan has confirmed that this facility is not a network provider with your plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to out-of-network services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to out-of-network services. The Plan has confirmed that this facility is out-of-network. This cost sharing 
is a contractual obligation that had not been met at the time the lab services was received on May 7, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the lab services you received 
from an out-of-network hospital on May 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mesalimine tablet 1.2mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug is self-administered and not covered. 
 
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 Mesalimine tablet 1.2mg 
for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on June 22, 2021. 
 
You asked the Plan to pay for lab tests. You say that this claim should be processed based on Medicare 
guidelines. The Plan denied your request. The Plan says the denial of payment for this testing is correct, 
because this testing was coded incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single procedure code shall be reported for the procedure.  
 We looked at the file and Medicare rules. This testing was not billed with a single procedure code and therefore 
has been coded inappropriately. Based on this information, we decided that Medicare rules for coverage of lab 
tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 5, 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. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
July 8, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have 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 must 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 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 out of network physician services provided to the 
enrollee on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on May 25, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you had to go to the 
dentist to see if your broken dentures could be repaired. The Plan denied your request. The Plan says this 
service is not covered. The Plan also says that when you contacted the Plan on May 24, 2021 you did not verify 
your exam benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 
problem focused limited oral evaluation (D0140) provided on May 25, 2021.