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

 
We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation procedure. 
 
You asked the Plan to pre-approve lumbar facet joint radiofrequency ablation 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 the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and 
necessary when specific criteria are met. 
 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 lumbar facet joint radiofrequency 
ablation procedure. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found in this case, there has not been a second confirmatory set of diagnostic medial branch blocks (MBBs). 
The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar facet joint radiofrequency ablation procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation 
procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth services (99443) provided on 
February 22, 2022. 
 
You asked the Plan to waive the copayment for the telehealth services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $30 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $30 copayment for telehealth services. Telehealth services fall within the 
Physician/Practitioner services, including doctors 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 telehealth services (99443) provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (85025) rendered by the out-of-
network (OON) provider on January 12, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (85025) rendered by the out-of-network (OON) provider on 
January 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo and Yervoy for the enrollee. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that these drugs are helpful for treatment of thyroid 
cancer. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drugs. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found low efficacy was 
reported from a phase II trial of the CTLA-4 inhibitor, ipilimumab, in combination with the PD-1 inhibitor, 
nivolumab, in 32 patients, with overall response rate of 9 percent and median progression-free survival 4.9 
months. This use is not Food and Drug Administration (FDA) approved, and is not supported by National 
Comprehensive Cancer Network (NCCN) guidelines, major drug compendia, or the medical literature. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdivo and Yervoy for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 8, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $50 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $46.80 copayment for an ultrasound, which is less than the standard $50. 
Ultrasounds 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 an ultrasound provided on November 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from October 1, 2021, to October 26, 2021. 
 
You asked the Plan to waive the copayment for the SNF care. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 per day for days 21-100 of Skilled nursing facility (SNF) care.  
 
 
  You have been asked to pay a $1,104 copayment for 6 days of SNF care. 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 skilled nursing facility (SNF) care provided from October 1, 2021, to October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient hospital services provided on 
October 15, 2021, and January 14, 2022 
 
You asked the Plan to waive the cost share for outpatient hospital services. You say that you would like a 
reduction in your bill. The Plan denied your request. The Plan says the deductible had not been met when 
services were received on October 15, 2021, nor had it been met for 2022 when services were received on 
January 14, 2022. 
 
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 $750 deductible. This is the amount you must pay out-of-pocket 
before the plan will pay their share for your covered medical services. Until you have paid the deductible 
amount, you must pay the full cost of your covered services which applies to surgery services. 
 
 
  The item or service you asked the Plan to waive the cost share for falls within the benefit category Outpatient 
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible. This is the amount you must pay out-of-pocket before the plan will pay their share for your 
covered medical services. Until you have paid the deductible amount, you must pay the full cost of your 
covered services. This cost sharing is a contractual obligation that had not been met at the time surgery services 
were received on October 15, 2021, and January 14, 2022. Therefore, we decided that the Plan does not have to 
waive the cost share for outpatient hospital services provided on October 15, 2021, and January 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray absorptiometry (77080) provided 
on January 6, 2022. 
 
You asked the Plan to waive the copayment for the x-ray absorptiometry. You say that the services should be 
covered as you disagree with the charges and never saw the doctor. The Plan denied your request. The Plan 
says the cost-sharing applied correctly based on the services provided, the cost-sharing assessed is for the exam 
itself and not for a doctors visit. 
 
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 outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a $35 copayment for an x-ray absorptiometry. X-ray absorptiometrys 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 an x-ray absorptiometry (77080) provided on January 6, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient mental health services provided 
from February 3, 2022, to February 24, 2022. 
 
You asked the Plan to waive the coinsurance for outpatient mental health services. You say that the 
coinsurance amount for this service was changed from 2021 to 2022 without notice. The Plan denied your 
request. The Plan says the coinsurance 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 20% 
coinsurance for each in-network Medicare-covered outpatient mental health care visit. The allowed amount of 
each claim is $149.90, resulting in a coinsurance amount of $29.98 ($149.90 x 20%) for each visit. 
 You have been asked to pay $89.94 for three (3) outpatient mental health care visits ($29.98 x 3). Outpatient 
mental health services fall 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 coinsurance for outpatient mental health services provided from February 3, 2022, to February 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 8, 2020. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says services provided by the member's daughter are 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for services provided by 
immediate family members.  In this case, the provider of service is the enrollee's daughter. Based on this 
information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, 
we decided that the Plan does not have to pay for medical services provided on November 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Methylenetetrahydrofolate Reductase (MTHFR) lab testing 
billed with code 81291 for date of service November 29, 2021. 
 
You asked the Plan to pay for the MTHFR testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MTHFR testing is non-covered for all indications 
except when performed for pregnant patients. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MTHFR testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Methylenetetrahydrofolate Reductase (MTHFR) lab testing billed with code 81291 for date of service 
November 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Inpatient Hospital services provided on July 30, 2021 to 
August 4, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Inpatient Hospital services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Inpatient Hospital services provided on July 30, 
2021 to August 4, 2021 by an out-of-network (OON) provider.
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 January 
26, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $35 copayment for a specialist office visit. Specialist 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 a specialist office visit provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care services provided on January 
10, 2022. 
 
You asked the Plan to waive the copayment for the vision care services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 Vision care.  
 
 
  You have been asked to pay a $15 copayment for vision care services. The record indicates that these services 
were performed by an optometrist specialist. 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 vision care 
services provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services you received on November 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that you do not understand how this could be denied 
because you said your dentist checked and said it was covered.  You said that you don't believe this dental 
insurance is worth it. The Plan denied your request. The Plan says you have exhausted your dental benefit for 
the year. 
 
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.  According to your Evidence 
of Coverage, your dental coverage is limited to $1500 per year.  The Plan has already paid $1500 towards 
dental services for you in 2021. 
 
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 pay for the dental 
services you received on November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ear microscopy (92504) provided on 
January 20, 2022. 
 
You asked the Plan to waive the copayment for the ear microscopy. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $20 copayment for an ear microscopy. Ear microscopies 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 an ear microscopy (92504) provided on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aflibercept injection (J0178) provided 
on February 8, 2022. 
 
You asked the Plan to waive the coinsurance for the aflibercept injection. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on the services provided. 
 
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 Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a 20% coinsurance for the aflibercept injection (allowed is $1,835.88 x 20% = 
$367.18). Aflibercept injections 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 an aflibercept injection (J0178) provided on February 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
13, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not request the 
ambulance and felt like you did not need to go to the hospital. The Plan denied your request. The Plan says the 
copayment 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 clearly says that you must pay a $300 
copayment for each Medicare-covered service or one-way trip by ground transportation. Copayment applies for 
evaluation, treatment, or transportation to the hospital for each Medicare-covered one-way trip. 
 
 
  You have been asked to pay $300 for ambulance services. Ambulance services fall within the Ambulance 
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 ambulance services 
provided on November 13, 2021.