Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the therapeutic exercises provided on 
December 8, 2021. 
 
You asked the Plan to waive the copayment for the therapeutic exercises. You say that you have a very limited 
income with no employment, and you cannot afford a $35 copay for each session. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for occupational or physical therapy visits.  
 
You have been asked to pay a $35 copayment for the therapeutic exercises. The therapeutic exercises fall 
within the Outpatient Rehabilitation 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 therapeutic exercises provided on December 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 9, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service April 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 19, 2022, to January 20, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not have to 
pay the $295 copay as the hospital staff gave you mediation causing your blood pressure to drop. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment each day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $295 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient Hospital 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 inpatient hospital stay provided from January 19, 2022, to January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services provided on April 14, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that the enrollee does not come to the 
lab which means they are not using their out-of-network benefits. You say the participating doctors sends the 
specimen. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
surgical pathology services. We found no exception that would require the Plan to pay for the surgical 
pathology services. The record shows the referring provider was out-of-network. Therefore, we decided that the 
Plan does not have to pay for the surgical pathology services provided on April 14, 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 copayment for occupational therapy (OT) services 
provided on February 18, 2022. 
 
You asked the Plan to waive the copayment for the OT services. You say that you were informed there would 
be no charge for the service. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for each occupational or speech therapy visit.  
 
You have been asked to pay a $15 copayment for the OT services. The OT services fall within the Outpatient 
Rehabilitation 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 
occupational therapy (OT) services provided on February 18, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mental health visit provided on March 29, 
2022. 
 
You asked the Plan to waive the copayment for a mental health visit. You say that you were not aware of how 
high this copayment would be, and no one notified you of this. The Plan denied your request. The Plan says the 
copayment applied was 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 $100 
copayment for outpatient mental health care in an outpatient hospital.  
 
You have been asked to pay a $100 copayment for a mental health visit. a mental health visit falls within the 
Outpatient Mental Health 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 a 
mental health visit provided on March 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an out-of-network Colorectal Screening provided 
on April 6, 2022. 
 
You asked the Plan to waive the cost for out-of-network Colorectal Screening. You say that this should be 
covered by the plan, and you should not have to pay. The Plan denied your request. The Plan says the cost 
applied was correct. You had not met your deductible yet at the time of this procedure, and it was preformed 
out-of-network. 
 
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 up to 
100% of the Medicare-approved amount for colorectal cancer screening.  
 
You have been asked to pay $508.87 of the Medicare-approved amount for out-of-network Colorectal 
Screening.Out-of-network Colorectal Screening falls within the Colorectal Cancer Screening 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 cost for an out-of-network Colorectal Screening provided on 
April 6, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
April 7, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you had fainted due to low blood 
sugar and were taken to the ER. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for emergency room visits.  
 
You have been asked to pay a $75 copayment for the ER visit. The ER visit 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 an emergency room (ER) visit 
provided on April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the walker and commode chair provided on 
April 6, 2022. 
 
You asked the Plan to waive the cost share for the walker and commode. You say that you say that when you 
received these items the bill you were given had a $0 balance. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1005 deductible which applies to Durable Medical Equipment 
(DME) and Related Supplies. At the time this claim was processed, $0 of the $1005 deductible had been met. 
The allowed amount of this claim is $98.82, resulting in a deductible amount of $98.82. 
 
The item or service you asked the Plan to waive the cost share for falls within the benefit category Durable 
Medical Equipment (DME) and Related Supplies. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $1005 deductible which applies to Durable Medical Equipment (DME) and 
Related Supplies. This cost sharing is a contractual obligation that had not been met at the time the walker and 
commode was received on April 6, 2022. Therefore, we decided that the Plan does not have to waive the cost 
share for the walker and commode chair provided on April 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the nuclear medicine study of heart muscle 
at rest and with stress provided on February 8, 2022. 
 
You asked the Plan to waive the cost share for the nuclear medicine study. You say that you were billed for two 
stress tests on the same day. You say you never received a nuclear stress test. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for each nuclear medicine study. Your contract with the Plan says that there is a $750 deductible 
which applies to nuclear medicine. At the time this claim was processed, $0 of the $750 deductible had been met. The allowed amount of this service is $1341.36, resulting in a deductible amount of $750. 
 
You have been asked to pay a $200 copayment for the nuclear medicine study for a total of $950 ($750 the 
deductible + $200 copayment = $950). The nuclear medicine study 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 cost share for the nuclear medicine study 
of heart muscle at rest and with stress provided on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 6, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services were 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 laboratory services provided on August 6, 2021, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right styloid process excision services. 
 
You asked the Plan to pre-approve right styloid process excision services. You say that the requested procedure 
is considered medically reasonable and necessary. The Plan denied your request. The Plan says there is no 
medical need for the requested surgery services as conservative treatments have not been ruled out at this time. 
 
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 right styloid process excision services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that based on available clinical documentation, the request for right 
styloid process excision does not meet criteria for coverage. Eagle or stylohyoid syndrome is a diagnosis of 
exclusion, and initial therapy is generally considered to include medical therapy administered orally (e.g., non-
steroidal anti-inflammatory drugs, anticonvulsants, analgesics) and/or via local injection (e.g., steroids, 
anesthetics), with surgery (styloidectomy) considered if medical therapy is unsuccessful. In this case, there was 
no documentation of evaluation for other potential causes of the enrollees symptoms, nor was there 
documentation to indicate that the enrollee had previously attempted medical therapy. Overall, the available clinical documentation did not show evidence of workup for other conditions that could also explain the 
enrollees symptoms, nor did it show previous attempts at conservative medical therapy. In summary, the 
requested services for right styloid process excision are 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 right styloid process excision services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve right styloid process excision services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on April 29, 2022. 
 
You asked the Plan to waive the copayment for office 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 $35 
copayment for each in-person specialist visit. Covered services include consultation, diagnosis, and treatment 
by a specialist. 
 
You have been asked to pay a $35 copayment for office visit. Office visits fall within the Physician/Practitioner 
services, including doctor's office visits 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 office visit on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dispensing fee (V5160), fitting/orientation/checking of 
hearing aid (V5011), and hearing aids (V5257) provided on January 31, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the dispensing fee, fitting/orientation/checking, and hearing aid. You say that 
you were unaware that hearing aids had to be purchased through the Plan's hearing aid vendor in order to be 
covered. The Plan denied your request. The Plan says you utilized a provider not in the vendor network. The 
Plan also says that hearing aids ordered through providers other than the Plan's hearing aid vendor are not 
covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor to use your hearing aid benefits. 
 
 
 
 We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the dispensing fee, fitting/orientation/checking, and hearing aid have not been met. Therefore, we 
decided that the Plan does not have to pay for the dispensing fee (V5160), fitting/orientation/checking of 
hearing aid (V5011), and hearing aids (V5257) provided on January 31, 2022, by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral superficial temporal artery ligation and 
transection of bilateral auricotemporal nerves for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this service is helpful for treatment of the health 
problem. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the consensus within current medical literature is that further study of this treatment approach is 
needed. In as much, given the need for further study in well-designed clinical trials, the proposed surgery 
remains investigational from the neurology perspective. As Medicare does not provide for coverage of 
experimental services, this would not be eligible for coverage at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral superficial temporal artery ligation and transection of bilateral auricotemporal 
nerves for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 provided on April 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lokelma. 
 
You asked the Plan to pre-approve Lokelma. You say that this drug has the more rapid onset of action. The 
Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part 
B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lokelma.  
 
 Benefits for Lokelma may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.