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

 
We decided that the Plan does not have to reimburse the coinsurance for frames (V2020), sphere lenses 
(V2100), and bifocal sphere lenses (V2200) provided on March 16, 2022. 
 
You asked the Plan to reimburse the coinsurance for frames (V2020), sphere lenses (V2100), and bifocal 
sphere lenses (V2200). You say that the provider had you pay up front to get the glasses. You also say that 
since Medicare pays for glasses after cataract surgery, this amount was wrong and should have been $0. 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 50% 
coinsurance for out-of-network Medicare-covered eyewear.  
 
 You have been asked to pay $77.18 in coinsurance, which is 50% of the allowed amount for frames (V2020), 
sphere lenses (V2100), and bifocal sphere lenses (V2200) ($155.34 allowed amount x 50% coinsurance = 
$77.18). You have also been asked to pay the difference between the out-of-network providers charges and the 
Plans payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
This item/service falls within the out-of-network Medicare-covered eyewear 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 reimburse the coinsurance for frames (V2020), sphere lenses (V2100), and bifocal sphere 
lenses (V2200) provided on March 16, 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 12, 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 
12, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a medical eye examination (92004) provided on July 19, 2022. 
 
You asked the Plan to pay for a medical eye examination (92004). You say that you do not understand why this 
exam is not completely covered. The Plan denied your request. The Plan says that the member went to an out-
of-network provider. 
 
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 Plan failed to provide medical records to prove why this non-routine eye 
examination code was considered routine or even why this was billed. Without the medical records, we are 
unable to verify if this was processed correctly. Therefore, we decided that the Plan has to pay for a medical 
eye examination (92004) provided on July 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 provided on March 14, 2022. 
 
You asked the Plan to pay for procedure code 93042. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93042 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 93042 provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on May 24, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you cannot afford the cost of the 
services. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for physician/practitioner services, including doctors office visits (specialist). 
 
You have been asked to pay a $45 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits (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 provided on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 
11, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the receptionist assured 
you that a copayment was not required for a follow-up visit 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 $35 
copayment for specialist visit. 
 
You have been asked to pay a $35 copayment for a specialist office visit. This item/service falls within the 
specialist visit 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 specialist office visit 
provided on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided from April 12, 2022, 
through May 3, 2022. 
 
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 these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the infrared therapy services provided have not been met.  Specifically, Medicare rules say that there is sufficient evidence to conclude that the use of infrared therapy 
devices and any related accessories is not reasonable and necessary. Therefore, we decided that the Plan does 
not have to pay for the infrared therapy (97026) provided from April 12, 2022, through May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 15, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
April 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on June 02, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you cannot afford this 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 $120 
copayment for Radiological diagnostic services. 
 
You have been asked to pay a $120 copayment for ultrasound. This item/service 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 ultrasound provided 
on June 02, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room visit followed by an 
inpatient stay provided from June 14, 2022, to June 17, 2022. 
 
You asked the Plan to waive the copayments for an ER visit followed by an inpatient stay. You say that you 
would like to have these fees waived. 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 per day for days 1-7 per admission for inpatient services, a $90 copayment for emergency care.  
$90 copayment for the ER - $250 x 3 days inpatient = $750 ($750 +$90 = $840). 
 
You have been asked to pay an $840 emergency care for an ER visit followed by an inpatient stay. 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 copayments for an emergency room visit 
followed by an inpatient stay provided from June 14, 2022, to June 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray provided on July 11, 2022. 
 
You asked the Plan to pay for x-ray. You say that you are appealing the claim payment denial. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for x-ray provided on July 
11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided on 
March 07, 2022, to March 18, 2022. 
 
You asked the Plan to waive the deductible for an inpatient hospital stay. You say that you have met your out-
of-pocket maximum 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 $1,260 
deductible for inpatient care. 
 
You have been asked to pay a $1,260 deductible for an inpatient hospital stay. This item/service falls within the 
inpatient care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the deductible for an inpatient hospital stay 
provided on March 07, 2022, to March 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durysta. 
 
You asked the Plan to pre-approve Durysta. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Durysta. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, you have corneal endothelial 
cell dystrophy. This is a contraindication to use. Bimatoprost intracameral implants are contraindicated for use 
in patients with corneal endothelial cell dystrophy. The review has determined that the requested use of Durysta 
is not FDA-approved for your diagnosis. Its use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durysta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durysta.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the remote interrogation device evaluation 
provided on March 09, 2022. 
 
You asked the Plan to waive the copayment for the remote interrogation device evaluation. You say that you 
only have one reading per month, but you were billed twice. 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 $35 
copayment for level 1 physician services. 
 
You have been asked to pay a $35 copayment for the remote interrogation device evaluation. This item/service 
falls within the level 1 physician 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.Please note that the provider confirmed there were two separate readings 
during the month of March. Therefore, we decided that the Plan does not have to waive the copayment for the 
remote interrogation device evaluation provided on March 09, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on February 19, 2022. 
 
You asked the Plan to pay for pathology services. You say that you would like this denial reconsidered as 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for pathology services 
provided on February 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 21, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that it was necessary to get the 
ultrasound done 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 a Medicare-covered ultrasound. 
 
You have been asked to pay a $100 copayment for an ultrasound. This item/service falls within the a Medicare-
covered ultrasound 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 ultrasound 
provided on July 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on November 01, 2021, to November 30, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that this should be 
covered. 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 $184 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $184 copayment for skilled nursing facility (SNF) care. This item/service falls 
within the Skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan.You have been asked to pay a $1,460 ($184 x 10 days) copayment which is 
less than the standard $1,840 copayment because you reached your out-of-pocket maximum during this claim. 
Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) 
care provided on November 01, 2021, to November 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from April 8, 2022, 
to May 5, 2022. 
 
You asked the Plan to pay for the home health care services. You say that you were not informed until the end 
of April that NOA's were a requirement for billing for the Plan. The Plan denied your request. The Plan says 
the admission date on the claim does not match the admission date on the NOA. 
 
The Plan must follow Medicare rules. Medicare rules say that the admission date on the NOA should match the 
admission date on all subsequent claims.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the admission date on the claim does not 
match the admission date on the NOA submitted. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Therefore, we decided that the Plan does not have 
to pay for the home health care services provided from April 8, 2022, to May 5, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit provided on 
July 21, 2022. 
 
You asked the Plan to waive the copayment for the emergency room (ER) visit. You say that the emergency 
room was your only option. 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 $85 
copayment for emergency care. 
 
You have been asked to pay a $85 copayment for the emergency room (ER) visit. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
(ER) visit provided on July 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service May 26, 
2022. 
 
You asked the Plan to pay for procedure code 93010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 93010 is bundled into 
payment for code 12001. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93010 
is a column II code to column I code 12001. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93010 billed for date of service May 26, 2022.