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

 
We decided that the Plan does not have to waive the copayment for colonoscopy on May 18, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that this was a wellness colonoscopy and 
not a diagnostic. You are requesting reconsideration. The Plan denied your request. The Plan says the cost 
sharing you are being charged is correct. 
 
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 $325 
copayment for each Medicare-covered outpatient hospital facility visit. If you are having surgery in a hospital 
facility, you should check with your provider about whether you will be an inpatient or outpatient. Unless the 
provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-
sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered 
an outpatient. 
 
 
 
 You have been asked to pay a $325 copayment for colonoscopy. Colonoscopy falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy on May 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on April 27, 2022, to 
May 07, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is 
correct. 
 
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 1-3: $0 per each additional day. 3 x $250 = $750. Therefore, results in the total 
cost sharing amount of $750.  
 
 
 
 
 You have been asked to pay a $250 copayment for days 1-3 of inpatient hospital stay. Inpatient hospital stay 
falls within the Inpatient Hospital Coverage 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 inpatient hospital stay on April 27, 2022, to May 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided May 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to change to a network dentist and 
were unaware there were frequency limits. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 18, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150) provided May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for teeth #10 and #11 provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you need these crowns. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on tooth #6 on date of service June 28, 
2022. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for teeth #10 and #11 
provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222 and D9223). 
 
You asked the Plan to pre-approve the deep sedation/general anesthesia. You say that you need to be sedated 
because the roots are in your sinus cavity, and you need teeth pulled. The Plan denied your request. The Plan 
says this service is not covered under your benefit plan. 
 
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 deep 
sedation/general anesthesia (D9222 and D9223).
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 March 3, 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 March 
3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse payment for 8 at home COVID-19 tests provided on May 
3, 2022 and May 6, 2022. 
 
You asked the Plan to reimburse payment for the 8 at home COVID-19 tests. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the items denied 
correctly as you are only eligible for 8 COVID-19 at home tests every 30 days, you already received 8 on 
04/16/2022. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
 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 payment for 8 at home COVID-19 tests provided on May 3, 
2022 and May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and laboratory testing (80307, 99214) 
provided on February 1, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and laboratory testing. 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 were non-emergent and prior authorization was not obtained. 
 
  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 an office visit and laboratory testing (80307, 
99214) provided on February 1, 2022 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for cardiovascular therapy visit on December 
29, 2021, to March 31, 2022. 
 
You asked the Plan to waive the copayments for cardiovascular therapy visit. You say that you want to appeal 
the amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 
is correct. 
 
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 $20 
copayment for $20 copayment for primary care visits and non-physician specialist visits that are not described 
elsewhere in this EOC Outpatient Care. There were 36 visits, $20 x 36 = $720. Therefore, results in the total 
cost sharing amount of $720. You have been asked to pay a $20 copayment for each cardiovascular therapy visit. Cardiovascular therapy 
visits fall within the Outpatient 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 copayments for 
cardiovascular therapy visit on December 29, 2021, to March 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array identified with code 64561. 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary.  
The Plan follows Medicare rules. Medicare rules say that nerve stimulation for urinary incontinence is only 
covered for certain 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 percutaneous implantation of 
neurostimulator electrode array. Our reviewer says that the documentation does not support that the requested 
services are medically reasonable or necessary. Our physician reviewer found the enrollee has frequency, 
urgency, urge incontinence, and incomplete bladder emptying. Cystoscopy shows benign prostatic hyperblasia. 
Urodynamics shows overactive bladder. The enrollee is currently doing fairly well with Myrbetriq, Tamsulosin 
and Oxybutynin. The enrollee has neurogenic bladder with post void residual of 358 cc. The prostate size is 30 
cc. The enrollee does not meet the coverage criteria for the requested services. The records show that the 
enrollee has diabetes with peripheral nerve involvement which excludes coverage of Interstim. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of 
neurostimulator electrode array identified with code 64561.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a mattress. You say that you are unable to sleep at night and is in a lot of 
pain due to hemorrhoids and a sore on your bottom that makes it very hard to sleep. The Plan denied your 
request. The Plan says the requested powered pressure-reducing air mattress is not medically necessary under 
Medicare. 
 
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 a mattress. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the enrollee has limited mobility due to her medical conditions. The documentation 
does not support that the enrollee has multiple stage 2 pressure ulcers located on the trunk or pelvis and has 
failed to improve in the previous month with conservative treatment with a comprehensive ulcer treatment 
program or a myocutaneous flap or skin graft. The requested pressure reducing support surface is not 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 a mattress have not been met. Therefore, we decided that the Plan does not have 
to pre-approve powered pressure-reducing air mattress (E0277).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammogram provided on May 4, 2022. 
 
You asked the Plan to waive the copayment for a mammogram. You say that no one told you that you would be 
charged for this. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $175 
copayment for each Medicare-covered outpatient diagnostic procedure and test in an outpatient facility.  
 
You have been asked to pay $160.98 which is less than the standard $175 copayment for a mammogram. 
Mammograms fall within the Outpatient Diagnostic Tests 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 a mammogram provided on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on June 07, 2021. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 20% 
coinsurance for Medicarecovered Part B Chemotherapy drugs and other Part B drugs. These drugs are covered 
under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan. 
Covered drugs include drugs that usually arent selfadministered by the patient and are injected or infused 
while you are getting physician, hospital outpatient, or ambulatory surgical center services. The provider billed 
in the amount of $2,552 and the allowed amount $991. $991 x 20% = $198.20. The provider also billed in the 
amount of $1,508 and the allowed amount is $585.60. $585.60 x 20% = $117.12. $198.20 + $117.12 = 
$315.32. Therefore, results in the total cost sharing amount of $315.32. 
 
 You have been asked to pay a 20% coinsurance for Part B drugs. Part B drugs fall within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Part B drugs on 
June 07, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the deductible for a biopsy performed on April 28, 2022. We also 
decided that the Plan has to waive the copayment for a hospital outpatient clinic visit on April 28, 2022. 
 
You asked the Plan to waive the deductible for a biopsy performed on April 28, 2022. You also asked the Plan 
to waive the copayment for a hospital outpatient clinic visit on April 28, 2022. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says that the cost share was applied 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 does not say in clear and accurate terms 
how much you should expect to pay for Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $200 
deductible for a biopsy and a $23.37 copayment for a hospital outpatient visit. The Plan contract does not 
clearly say how much enrollees must pay for Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers. This means that the Plan did not follow Medicare rules 
for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the deductible for a 
biopsy performed on April 28, 2022,  and the copayment for a hospital outpatient clinic visit on April 28, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on May 3, 2022 
 
You asked the Plan to waive the copayment for an MRI. You say that this should only be a $20 copayment, not 
$150. The Plan denied your request. The Plan says you were charged this cost sharing 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 $150 
copayment for outpatient hospital services.  
 
You have been asked to pay a $150 copayment for an MRI. An MRI 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 magnetic resonance imaging (MRI) provided 
on May 3, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation, per site 
(D7953). 
 
You asked the Plan to pre-approve the dental services. You say that this procedure is imperative to your quality 
of life. Without the graft, any denture will not adhere properly in your mouth. The Plan denied your request. 
The Plan says the requested procedure does not appear on the list of covered services. 
 
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 bone 
replacement graft for ridge preservation, per site (D7953).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory work provided on February 10, 
2021. 
 
You asked the Plan to waive the deductible for laboratory work. You say that this bill came unacceptably late. 
You were not told about this cost and feel it should be a The Plan denied your request. The Plan says you were 
charged this cost sharing 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 $500 
deductible for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the $422.13 deductible for laboratory work. laboratory work falls within the 
Outpatient Diagnostic Tests 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 deductible for laboratory work provided on February 10, 2021.   
Your complaint about staffing is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown (D6066). 
 
You asked the Plan to pre-approve the implant supported crown. You say that the original root canal that was 
done nine years ago was cracked and not repairable any other way. The Plan denied your request. The Plan 
says this service is not covered. 
 
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 an 
implant supported crown (D6066).