Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on December 05, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you thought this was still 
considered a follow-up appointment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for primary care physician/practitioner services. 
 
You have been asked to pay a $15 copayment for the office visit. This item/service falls within the primary 
care physician/practitioner 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. The records show this was not a follow-up appointment. Therefore, we decided 
that the Plan does not have to waive the copayment for the office visit provided on December 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on October 21, 2022. 
 
You asked the Plan to pay for a specialist office visit. You say that you was unaware that she wasnt in 
network. 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 a specialist office visit 
provided on October 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the automated external defibrillator 
provided on November 26, 2022. 
 
You asked the Plan to waive the coinsurance for the automated external defibrillator. You say that you did not 
like this equipment and returned it. 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 20% 
coinsurance for durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the automated external defibrillator. This item/service falls 
within the durable medical equipment and related 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. The total you owe is $616.19 ($3,080.95 allowed 
amount x 20% coinsurance = $616.19). Therefore, we decided that the Plan does not have to waive the 
coinsurance for the automated external defibrillator provided on November 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care service provided on October 
24, 2022. 
 
You asked the Plan to waive the copayment for the urgent care service. You say that you should not be 
responsible for the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for urgently needed services. 
 
You have been asked to pay a $25 copayment for the urgent care service. This item/service falls within the 
urgently needed 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 urgent 
care service provided on October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 02, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was in a nursing home and 
cannot choose providers. 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 the laboratory services 
provided on November 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the primary care office visit provided on 
May 13, 2022. 
 
You asked the Plan to waive the coinsurance for the primary care office visit. You say that you were told there 
was no copayment due to COVID. 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 primary care physician/practitioner services.  
You have been asked to pay 50% coinsurance for the primary care office visit. This item/service falls within 
the out-of-network primary care physician/practitioner 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. The total you owe is $39.86 ($79.73 allowed 
amount x 50% coinsurance = $39.86). Therefore, we decided that the Plan does not have to waive the 
coinsurance for the primary care office visit provided on May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the Prolia injection provided on 
December 28, 2022. 
 
You asked the Plan to reduce the coinsurance for the Prolia injection. You say that you were quoted a 
copayment of $9.85. 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 20% 
coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the Prolia injection. This item/service falls within the in-
network 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 reduce the coinsurance for 
the Prolia injection provided on December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 05, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. 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 laboratory services 
provided on May 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 22, 2022. 
 
You asked the Plan to pay for an office visit. You say that you want to have this bill paid back to you. 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 an office visit provided 
on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on November 08, 2022. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the enrollee was in a nursing home and 
cannot choose providers. 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 the subsequent nursing 
care provided on November 08, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. 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 follows Medicare rules. Medicare rules say that thermal destruction of the intraosseous BVN will be 
considered medically reasonable and necessary for the treatment of cLBP in patients who meet specific criteria. 
 
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 Intracept procedure. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the magnetic resonance 
imaging (MRI) shows disc bulges and foraminal stenosis. The cause of back pain is unclear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
January 10, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this should be paid in 
full since you were not made aware of the cost for this service. 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 $40 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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. However, since the allowed amount is less than the standard 
copayment, you only owe $39.76. Therefore, we decided that the Plan does not have to waive the copayment 
for the specialist office visit provided on January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture and complete upper denture 
(D5214, D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental 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 pre-approve a 
partial lower denture and complete upper denture (D5214, D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the single vision lenses, and the miscellaneous 
vision item provided on December 4, 2022. 
 
You asked the Plan to pay for the frames, the single vision lenses, and the miscellaneous vision item. You say 
that you thought you were covered for new glasses from January 1 to December 31, and not 365 days for the 
last date of service. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 the frames and lenses once every year and does not cover the miscellaneous vision 
item. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for frames and lenses on December 28, 
2021, which exhausted the benefit. Also, the miscellaneous vision item is not a covered service. Based on this 
information, we decided that the Plan's rules for coverage of the frames, the single vision lenses, and the 
miscellaneous vision item have not been met. Therefore, we decided that the Plan does not have to pay for the 
frames, the single vision lenses, and the miscellaneous vision item provided on December 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive medicine reevaluation and management 
provided on July 08, 2022. 
 
You asked the Plan to pay for the preventive medicine reevaluation and management. You say that the charge 
is for a pneumonia vaccine and should be covered. 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 the preventive medicine 
reevaluation and management provided on July 08, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0482 provided on November 21, 2022. 
 
You asked the Plan to pay for procedure code G0482. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the records do not support the services 
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, the CPT Code Manual definition of 
code G0482 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records support that 19 drug 
classes were tested, including Alcohol biomarkers, Amphetamines, Benzodiazepines, Buprenorphine, 
Cannabinoids-natural, Fentanyls, Gabapentin-non-blood, Heroin metabolite, Methadone, 
Methylenedioxyamphetamines, Methylphenidate, Opiates, Opioids and opiate analogs, Oxycodone, 
Phencyclidine, Pregabalin, Skeletal muscle relaxants, Tapentadol, and Tramadol. Based on this information, we 
decided that Medicare rules for coverage of procedure code G0482 have been met. Therefore, we decided that 
the Plan has to pay for procedure code G0482 provided on November 21, 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 a chiropractic visit provided on September 09, 2022. 
 
You asked the Plan to pay for a chiropractic visit. You say that this was medically necessary and should be 
covered. 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). There are other in-network providers within the allowable proximity to this 
beneficiarys residence. Therefore, we decided that the Plan does not have to pay for a chiropractic visit 
provided on September 09, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute inpatient stay provided on August 10, 2022, to 
August 13, 2022. 
 
You asked the Plan to pay for an acute inpatient stay. You say that please review medical records, this patient 
needed to be watched. Please review again. 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). Due to how the patient was progressing from the time they were in the emergency 
room, to the inpatient room, this was not deemed as an emergency. Therefore, we decided that the Plan does 
not have to pay for an acute inpatient stay provided on August 10, 2022, to August 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on August 23, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the records attached support the 
services provided. 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 domiciliary or rest home 
visit provided on August 23, 2022.