Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for inpatient hospital care provided on June 
28, 2022, to July 7, 2022. 
 
You asked the Plan to reduce the copayment for inpatient hospital care. You say that you were told that there 
would be a onetime admission fee of $300. 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 $350 
copayment for days 1-5 and $0 after day 5. This inpatient hospital stay lasted 9 days, resulting in a copayment 
of $1,750 ($350 per day for 5 days = $1,750). 
 
You have been asked to pay $350 copayment per day for inpatient hospital care. This item/service falls within 
the days 1-5 and $0 after day 5 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 
inpatient hospital care provided on June 28, 2022, to July 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT provided on June 9, 2022. 
 
You asked the Plan to waive the copayment for the CT. 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 $300 
copayment for Medicare-covered diagnostic radiology services (not including x-rays).  
 
You have been asked to pay a total of $132.68, which is less that the standard $300 copayment for the CT. This 
item/service falls within the Outpatient Diagnostic 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 the CT provided on June 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ambulance transportation provided on 
April 02, 2022. 
 
You asked the Plan to reduce the copayment for the ambulance transportation. You say that you believe the 
copayment is too much and would like it lowered 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 $250 
copayment for each one-way Medicare-covered ground ambulance trip. 
 
You have been asked to pay a $250 copayment for the ambulance transportation. This item/service falls within 
the each one-way Medicare-covered ground ambulance trip 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 the ambulance transportation provided on April 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve. 
 
You asked the Plan to pre-approve thermal destruction of intraosseous basivertebral nerve. You say that 
thermal destruction of intraosseous basivertebral nerve is medically necessary. The Plan denied your request. 
The Plan says the requested intracept procedure is not medically necessary based on the medical literature. 
 
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 thermal destruction of intraosseous 
basivertebral nerve. Our reviewer says that thermal destruction of intraosseous basivertebral nerve is not 
considered medically reasonable and necessary. Our physician reviewer found this is considered an 
experimental/investigational procedure. Therefore, the request is considered not medically reasonable and 
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 thermal destruction of intraosseous basivertebral nerve have not been met. Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous 
basivertebral nerve.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic tests provided on June 21, 2022. 
 
You asked the Plan to waive the copayment for diagnostic tests. You say that you do not agree with the 
member responsibility for this claim. 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 diagnostic procedures and tests. 
 
You have been asked to pay a $100 copayment for diagnostic tests. This item/service falls within the diagnostic 
procedures and tests 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 diagnostic tests 
provided on June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service January 19, 
2022. 
 
You asked the Plan to pay for procedure code 99072. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99072 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service January 19, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT), of the thorax, diagnostic; with 
contrast material(s) (71260). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 this service. Our reviewer says that this 
service is medically necessary. Our physician reviewer found that the enrollee had a positive low-dose 
computed tomography scan (LDCT) on March 21, 2022 and a cardiac calcium scoring scan. A follow-up CT 
scan is indicated by the enrollee's history. The coronary calcium scoring exam was insufficient to follow 
nodules. A repeat diagnostic CT scan of the chest is appropriate at six months and should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT), of the thorax, diagnostic; with contrast material(s) (71260).  
 
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 pay for office visit provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says as a member of our plan, the enrollee must use network providers. If the enrollee 
receives unauthorized care from an out-of-network provider, we may deny coverage and you will be 
responsible for the entire cost. 
 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 office visit provided on February 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for smoking and tobacco use cessation counseling visit provided 
on July 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for smoking and tobacco use cessation counseling visit. You say that this provider 
regularly complies with all administrative requirements for payments. The Plan denied your request. The Plan 
says this provider is not a network provider with the Plan. The Plan also says these services were not approved 
in advance. 
 
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 smoking and tobacco use cessation counseling 
visit provided on July 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on June 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim processed for payment. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no approved authorization. Also, the service rendered 
was not urgent or emergent. 
 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 home health visit provided on June 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nervous system surgery provided on March 8, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that the provider is in-network, and you were 
authorized to see them. The Plan denied your request. The Plan says the rendering provider is an OON provider 
and there was no approved authorization. Also, the service rendered was not urgent or emergent. 
 
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 the nervous system surgery provided on March 8, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor and supplies to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compressor and supplies. You say that the enrollee needs the 
requested devices to begin prompt treatment. The Plan denied your request. The Plan says the service can be 
provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 
pneumatic compressor and supplies to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for hospital discharge services provided by an 
out-of-network provider on May 13, 2022. 
 
You asked the Plan to waive the deductible for hospital discharge services. You say that you believe were 
being charged for an out of network charge. 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  $750 
deductible for most out-of-network services. 
 
You have been asked to pay a $101.50 that goes towards your $750 deductible for hospital discharge 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. This cost sharing is a contractual obligation that had not been met at the 
time hospital discharge services were received on May 13, 2022. Therefore, we decided that the Plan does not have to waive the deductible for hospital discharge services 
provided by an out-of-network provider on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for frames (V2020), lenses (V2107) anti-reflective lens 
coating (V2750) and single eyeglass lens (V2103) provided on June 15, 2022. 
 
You asked the Plan to reimburse for frames (V2020), lenses (V2107) anti-reflective lens coating (V2750) and 
single eyeglass lens (V2103). You say that you are requesting your second annual eye care reimbursement of 
$250. You also say that it is not exhausted for the 2022 year. The Plan denied your request. The Plan says the 
$250 eyewear benefit allowance was exhausted with this purchase. 
 
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 a $250 allowance for eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that you are responsible for any amount over the 
$250 allowance for eyewear. The record shows you were provided the $250 allowance for your eyewear on 
June 15, 2022. Based on this information, we decided that the Plan's rules for coverage of frames (V2020), 
lenses (V2107) anti-reflective lens coating (V2750) and single eyeglass lens (V2103) have not been met. 
Therefore, we decided that the Plan does not have to reimburse for frames (V2020), lenses (V2107) anti-
reflective lens coating (V2750) and single eyeglass lens (V2103) provided on June 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for a provider appointment. 
 
You asked the Plan to pre-approve additional mileage for an appointment. The Plan denied your request. The 
Plan says your plan covers a maximum trip distance of 60 miles per one-way trip. The Plan also says that 
additional mileage is not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 60 miles.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage for a provider appointment.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service provided on July 14, 
2022. 
 
You asked the Plan to waive the copayment for ambulance service. You say that you cannot afford to pay this 
bill. 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 $350 
copayment for one-way trip for Medicare-covered ambulance service.  
 
You have been asked to pay $350 copayment for ambulance service. This item/service falls within the one-way 
trip for Medicare-covered ambulance service 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 ambulance service provided on July 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has age-related 
osteoporosis without current pathological fracture. She has not tried and failed the Plan's required drugs, an oral 
bisphosphonate and zoledronic acid. The records do not support that the required drugs are contraindicated or 
less effective; therefore, Prolia is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for platelet rich plasma provided on February 22, 2022. 
 
You asked the Plan to pay for platelet rich plasma. You say that platelet rich plasma is medically necessary. 
The Plan denied your request. The Plan says platelet rich plasma does not meet the Medicare LCD coverage 
criteria. 
 
The Plan follows Medicare rules. 
 
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 pay for platelet rich plasma. Our reviewer says that 
platelet rich plasma is not medically necessary. Our physician reviewer found enrollee is a 70-year-old female 
with left knee pain related to osteoarthritis. It was reported that prior platelet rich plasma injections had helped 
her. This procedure, however, is listed specifically as a non-approved procedure under LCD Medicare criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of platelet rich plasma have not been met. Therefore, we decided that the Plan does 
not have to pay for platelet rich plasma provided on February 22, 2022.