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

 
We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on 
April 24, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 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 out of network medical services provided to the 
enrollee on April 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77002-26 billed for date of service August 
13, 2021. 
 
You asked the Plan to pay for procedure code 77002-26. You say that separate procedures were performed. The 
Plan denied your request. The Plan says payment for code 77002-26 is bundled into payment for code 51705. 
 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 
77002-26 is a column II code to column I code 51705. 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 77002-26 billed for date of service 
August 13, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Darzalex Faspro. 
 
You asked the Plan to pre-approve Darzalex Faspro. You say that the provider has a preference for the drug 
submitted. The Plan denied your request. The Plan says the enrollee has not tried the preferred drug. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We looked at the file, and Medicare rules. The Plan requires a trial of Velcade before they will approve the 
requested drug. The documentation does hot show that the enrollee has tried and failed the preferred drug. 
There are insufficient medical records to show that the Plans required drug would likely be less effective or 
likely have adverse effects for the enrollee. Based on this information, we decided that Medicare rules for 
coverage of Darzalex Faspro have not been met. Therefore, we decided that the Plan does not have to pre-
approve Darzalex Faspro.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), lenses (V2200), antireflective coating 
(V2750), and tint (V2744) received on February 24, 2022, by an out-of-network provider. 
 You asked the Plan to pay for frames, lenses, antireflective coating, and tint. You say that you chose this 
provider because the lenses are cheaper. The Plan denied your request. The Plan says the provider was non-
contracted by the Plan, and the service was not pre-authorized. 
 
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 these services with an out-of-network provider when the services are pre-authorized. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of frames, lenses, antireflective coating, and tint have not been met. Therefore, we decided that the 
Plan does not have to pay for frames (V2020), lenses (V2200), antireflective coating (V2750), and tint (V2744) 
received on February 24, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the high frequency chest wall oscillation device provided on 
April 10, 2022. 
 
You asked the Plan to pay for the high frequency chest wall oscillation device. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested device was not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 
 While the record does show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease, the documentation shows that the enrollee stopped using this device shortly after set up on February 
10, 2022. The enrollee had non-compliance for the dates of service billed. This means that the enrollee did not 
meet criteria which a high frequency chest wall oscillation device can be paid for by Medicare. Therefore, we 
decided that the Plan does not have to pay for the high frequency chest wall oscillation device provided on 
April 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional trips. You say that you are unable to drive. The Plan denied your 
request. The Plan says additional trips are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. The records show that you used 16 trips at 
the time of the request. Once you have used 20 trips you will have exhausted the Plan maximum benefit for 
coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited breast ultrasounds (76642) provided on February 
14, 2022. 
 
You asked the Plan to pay for the limited breast ultrasounds. You say that these tests were for comparison to 
prior imaging studies. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 23, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the limited breast ultrasounds have not been 
met. Therefore, we decided that the Plan does not have to pay for the limited breast ultrasounds (76642) 
provided on February 14, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on May 17, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the drug testing provided on May 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for 17 radiation treatments provided from 
January 19, 2022, to February 15, 2022. 
 
You asked the Plan to waive the copayments for radiation treatments. You say that you feel this number of 
copayments are excessive for the treatments received. The Plan denied your request. The Plan says the 
copayments 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 $60 
copayment for outpatient diagnostic tests and radiation (radium and isotope) therapy. You had $60 copayment 
x 17 treatments = $1020. 
 
You have been asked to pay a $1020 copayment for radiation treatments. Radiation treatment falls within the 
Outpatient Diagnostic Tests and Radiation (Radium and Isotope) Therapy 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 17 radiation treatments 
provided from January 19, 2022, to February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oximeter you purchased on February 5, 2022. 
 
You asked the Plan to pay for the oximeter. You say that your doctor prescribed this oximeter. The Plan denied 
your request. The Plan says items you purchase from a durable medical equipment (DME) vendor who does 
not participate with Medicare are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the oximeter you purchased on February 
5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasounds of the right breast and left breast (76641) 
provided on January 26, 2022. 
 
You asked the Plan to pay for the ultrasounds. You say that the enrollee had multiple exams on this date of 
service, and you would like this claim to be reconsidered for processing. The Plan denied your request. The 
Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
  We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 23, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the ultrasounds have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasounds of the right breast and left breast 
(76641) provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were the provider available at the time as a 
result of an emergency situation. You say the service was medically necessary. 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on January 28, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the $100 copayment for emergency care on February 21, 2022.       
 
You asked the Plan to waive the $100 copayment for emergency care on February 21, 2022. You say that you 
would like the copayment waived because you have not been charged for emergency care before. The Plan 
denied your request. The Plan says that you asked the Plan to waive the $100 copayment for emergency care on 
February 21, 2022. The Plan has not included your appeal request in the submitted documentation. The Plan 
says this claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided evidence of your appeal request or your 
argument for waiving the copayment. Without this documentation we are unable to determine what is at appeal 
or if the case has been processed appropriately. It is the burden of the Health Plan to substantiate their denial 
with evidence. In this case, the Plans denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to waive the $100 copayment for emergency care on February 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on September 21, 
2021. 
 
You asked the Plan to waive the copayment for lab services. You say that you should not have to pay this 
copayment because you feel the lab made an error. 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 $30 
copayment for in-network Medicare-covered lab services. You have been asked to pay the allowed amount of 
$11.46 which is less than the $30 copayment. 
 
You have been asked to pay a $11.46 copayment for lab services. Lab services falls within the In-Network 
Medicare-Covered Lab 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 
lab services provided on September 21, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has waive the $225 copayment for advanced imaging services performed on January 
31, 2022. 
 
The Plan says you asked the Plan reduce the $225 copayment for advanced imaging services. You say that the 
copayment should be reduced because you were not told there would be a $225 copayment. The Plan denied 
your request. The Plan says that this claim processed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded the EOC. Without the contract, we are 
unable to verify your benefits and determine if the cost sharing has been applied correctly. It is the burden of 
the Health Plan to substantiate their denial with evidence. In this case, the Plans denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to waive the $225 
copayment for advanced imaging services performed on January 31, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) and 
the intraoral-periapical additional radiographic images (D0230 x 5) provided on April 12, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-
periapical first radiographic image (D0220) and the intraoral-periapical additional radiographic images  
(D0230 x 5) provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit and debridement service provided on 
October 29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit and the debridement service. You say that the service was 
medically necessary. 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 
domiciliary visit and the debridement service. We found no exception that would require the Plan to pay for the 
domiciliary visit and the debridement service. The records provided for review do not show that the services at 
issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary 
visit and debridement service provided on October 29, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laparoscopy services and to pay for the 
oral drug provided on March 23, 2022.  
You asked the Plan to waive the copayment for the laparoscopy services and to pay for the oral drug. You say 
that you do not want to pay the member responsibility and you do not know what the medicine was. The Plan 
denied your request. The Plan says the claim has been processed correctly per your Plan benefits. 
 
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 for outpatient surgery. The rules also say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs received here are not among the types which are covered by 
Medicare Part B. 
 
You have been asked to pay a $250 copayment for the laparoscopy services and to pay for the oral drug. The 
laparoscopy services fall within the Outpatient Surgery benefit category. The self-administered drug is non-
covered. 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 laparoscopy services and to pay for the oral 
drug provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5050) provided on March 9, 2022 from an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that the Plan does not offer the services you needed, 
which is why you did not use an in-network provider. The Plan denied your request. The Plan says this service 
was not authorized by network/primary care providers. 
 
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 receive authorization for OON covered services.  
 
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 hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5050) provided on March 9, 2022 from an out-of-network (OON) provider.