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

 
We decided that the Plan does not have to pay for physician services provided on May 4, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician services provided on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on February 
15, 2022. 
 
You asked the Plan to waive the copayment for the specialist services. You say that you feel that you are being 
charged extra for the services. 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 specialist services.  
 
You have been asked to pay a $35 copayment for the specialist services. The specialist services 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 specialist services provided on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 25, 
2022, March 8, 2022, and April 19, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you are constantly trying to fix this 
copayment issue, you should not have all these copayments. The Plan denied your request. The Plan says the 
copayments that were applied were 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 $10 
copayment for Medicare covered primary care provider office visit. You had 3 appointments, resulting in a $30 
totally copayment amount ($10 x 3 = $30). 
 
You have been asked to pay a $30 copayment for an office visit. An office visit falls 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 an office visit provided on January 25, 2022, March 8, 2022, and April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on April 20, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 tests. You say that you would like to know if the at-
home COVID-19 tests might be covered as a supplemental benefit under your plan, even though it is not a 
requirement. The Plan denied your request. The Plan says OTC at-home COVID-19 testing kits are not eligible 
for reimbursement by Medicare or Medicare Advantage plans. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 tests are an OTC item. The Plan does not offer a supplemental benefit covering this service as this 
is not currently required by Medicare. However, for future purchases, these can be obtained with participating 
providers and covered by Original Medicare when using your Medicare card rather than your Plan card. 
Neither Medicare nor your Plan currently offers reimbursement of purchased COVID-19 tests. Therefore, we 
decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment services (97810, 97811, 97814) 
provided from October 1, 2021, through December 29, 2021. 
 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 the services are not payable as they were 
rendered by an ineligible provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services in this case were performed by an 
acupuncturist who was not under the supervision of a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture treatment services (97810, 97811, 97814) provided from October 1, 2021, through December 29, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), heart, without contrast 
material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve the imaging service. You say that the test is needed for a coronary calcium 
score. You also say that this will help to determine if adjustments in their treatment need to be made. The Plan 
denied your request. The Plan says the requested service was denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 75571 is not a covered service. 
Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT), heart, without 
contrast material, with quantitative evaluation of coronary calcium (75571).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 5, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 5, 2022, billed with codes 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, and 
0033U.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam and eye x-ray provided on January 20, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an eye exam and eye x-ray. You say that this service should have been covered. 
The Plan denied your request. The Plan says services from non-participating providers for vision services are 
not covered under the Plan unless they are authorized by the Plan before the services are provided. 
 
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 eye exam and eye x-ray provided on January 
20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481, 87529, 87556, 87491) provided 
on April 14, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 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 laboratory services (87481, 87529, 87556, 87491) 
provided on April 14, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), and laboratory 
services (36415, 83520, 80053, 82728, 85025) provided on May 25, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the outpatient and laboratory services. You say that the medically necessary 
services were rendered to the enrollee in good faith. The Plan denied your request. The Plan says the claim 
processed correctly. 
 
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 did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the hospital outpatient clinic visit (G0463), and laboratory services (36415, 
83520, 80053, 82728, 85025) provided on May 25, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you have glaucoma in both eyes and 
cannot see all the time. You also say that you need to be able to get to doctor's appointments on the days you 
cannot drive. The Plan denied your request. The Plan says you have used all of the 12 covered one-way trips 
you are allowed. 
 
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 up to 12 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wellness visit provided on May 20, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the wellness visit. 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 a wellness visit provided on May 20, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the services requested are medically necessary. 
The Plan denied your request. The Plan says your medical record shows your condition can be managed by a 
general dermatologist. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Zirabev (Q5118). 
 
You asked the Plan to pre-approve Zirabev. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical-necessity rules have not been met because the 
requested drug is prescribed for an off-label and not medically supported use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Zirabev. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Zirabev is not FDA-approved for the enrollees diagnosis. Furthermore, the use is not 
supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved 
medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zirabev have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Zirabev (Q5118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under the 
enrollees contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Acetaminophen and Oxycodone-Acetaminophen 
provided on May 6, 2022. 
 
You asked the Plan to pay for the Acetaminophen and Oxycodone-Acetaminophen. You say that all the drugs, 
either prescribed or over the counter, were directed from your doctor. The Plan denied your request. The Plan 
says Acetaminophen and Oxycodone-Acetaminophen are self-administered drugs, and are not covered under 
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 pay for the Acetaminophen and 
Oxycodone-Acetaminophen provided on May 6, 2022.  
 Benefits for the Acetaminophen and Oxycodone-Acetaminophen may be available under Medicare Part D. 
Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal 
rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided by a 
participating provider on March 3, 2021. 
 
You asked the Plan to pay for intraoral imaging. You say that you had no idea that the x-rays taken were not a 
standard operating procedure. The Plan denied your request. The Plan says D0230 and D0220 are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral 
imaging (D0220 and D0230) provided by a participating provider on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 4, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 the laboratory services provided on February 4, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reinstate OTC benefit. 
 
You asked the Plan to reinstate OTC benefit. You say that since you were not given the information on a timely 
basis, you missed the first and second over-the-counter quarters. You also say that the first two quarters should 
be reinstated. The Plan denied your request. The Plan says quarterly allowances cannot be carried over to 
another quarter. 
 
Though the Plan offers OTC benefits in excess of Medicare coverage, the OTC allowance cannot be carried 
over to another quarter. Therefore, we decided that the Plan does not have to reinstate OTC benefits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper 
extremity. 
 
You asked the Plan to pre-approve a MRI. You say that the patient had an x-ray of the shoulder and it did not 
show that you were looking for, which was a tear in the shoulder. The Plan denied your request. The Plan says 
MRI of the upper extremity is not medically necessary. There is no evidence of physical therapy, six weeks of 
conservative treatment or other medications tried. Only minimal medical records were supplied to support the 
need for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 a MRI. Our reviewer says that 
the requested MRI is not medically necessary. Our physician reviewer found there are no medical records aside 
from an x-ray report of the right shoulder. Absent such records medical necessity cannot be established. 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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI) of the upper extremity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 You asked the Plan to pre-approve genetic testing.. You say that this test is medically necessary. You have 
digestive issues, and it could help to identify issues. The Plan denied your request. The Plan says you do not 
have a diagnosis of cancer therefore this test is not medically necessary. 
 
We looked at the file and Medicare rules. The record shows the genetic testing panel was not requested for a 
cancer diagnosis. Based on this information, we decided that Medicare rules for coverage of genetic testing. 
have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA genetic testing.