Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve additional transportation mileage. 
 
You asked the Plan to pre-approve additional transportation mileage. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says that the services are not covered. 
 
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 routine transportation and prior authorization is required where the travel distance to a 
provider exceeds the mileage limit of 60 miles. Trip distance exceeding 60 miles per one-way trip are not 
covered except when transportation is needed to obtain specific medically necessary Medicare or Plan covered 
services.  
 
Medicare rules also 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.  
 
Medicare rules also say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
We looked at your request, the records in the case file, and the rules. 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 contract says that additional mileage can be covered if transportation is needed to obtain 
specific medically necessary Medicare or Plan covered services.  The file shows there is concern that you have 
no local providers available to you that can provide care for your specific condition. The Plan did not address 
this issue of concern to determine if, per the Plan contract, the additional mileage would meet their exception 
criteria.  
 
Therefore, we decided that the Plan has to pre-approve additional transportation mileage.  
 
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 pay for lab services provided on February 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. 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, for 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 lab services 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 lab services provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain or ceramic crown (D2740). 
 
You asked the Plan to pre-approve a porcelain or ceramic crown (D2740). You say that you need a crown 
because your gums are swelling when you eat. The Plan denied your request. The Plan says this service is not 
medically necessary. 
 
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. The Plan covers a porcelain or 
ceramic crown (D2740) when the services are medically necessary and reasonable.  
 
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 porcelain or ceramic crown (D2740). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
provided does not meet the criteria for coverage for a crown restoration (D2740) for tooth #21. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a porcelain or ceramic crown (D2740) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a porcelain or ceramic crown (D2740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. 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, for 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 lab services 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 lab services provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 20, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on August 12, 2022. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for surgery provided on 
August 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a computed tomography (CT) scan of the head provided on June 20, 
2022. 
 
You asked the Plan to pay for the CT scan. You say that the facility is responsible for obtaining authorization. 
The Plan denied your request. The Plan says that services should be received from network providers, except 
when urgent or an emergency. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 pay for the CT scan. Our reviewer says that the 
records indicate that the care provided was medically necessary. Our physician reviewer found the enrollee had 
a cardiac and a neurologic condition at the time of evaluation.  It would not have been safe to require the 
enrollee to travel out of state to have the scan based upon their history and recent trauma. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pay for a 
computed tomography (CT) scan of the head provided on June 20, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nail provided on September 23, 2022. 
 
You asked the Plan to pay for debridement of nail. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for debridement of nail 
provided on September 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. 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, for 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 lab services 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 lab services provided on July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on October 
18, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you thought there was a 
certain amount of time you had to follow-up with the provider after a hospital stay without paying a 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $40 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for specialist office visit. This item/service 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 specialist office visit provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or 
more beneficial than Intensity modulated radiation therapy/Image-guided radiation therapy (IMRT/IGRT). The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist office visit 
provided on September 28, 2022. 
 
You asked the Plan to waive the copayment for an in-network specialist office visit. You say that you should 
not have this copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for an in-network specialist office visit. This item/service 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 in-network specialist office visit provided on September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary. 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, for 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 lab services 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 lab services provided on June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Opioid treatment programs provided on October 10, 2022. 
 
You asked the Plan to pay for Opioid treatment programs. The Plan denied your request. The Plan says 
payment is not allowed for this claim because it does not meet the opioid treatment program criteria for 
payment. Per CMS, we can only pay opioid treatment program claims for SAMHSA certified provider. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Opioid treatment programs have not been met. Therefore, we decided that the Plan does not have 
to pay for Opioid treatment programs provided on October 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance non-emergent transport provided on August 31, 
2022. 
 
You asked the Plan to pay for ambulance non-emergent transport. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ambulance non-
emergent transport provided on August 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 15, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that this was denied for no authorization. You also say 
you would like this reconsidered. The Plan denied your request. The Plan says this provider was not 
certified/eligible to be paid for this procedure/service on this date of service. 
 
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 psychotherapy provided on September 
15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) on 
September 01, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $225 
copayment for complex radiological services (CT, MRI, and PET scan). Covered services include but are not 
limited to diagnostic radiological services (both complex and non-complex) such as specialized scans, CT, 
SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional 
radiological procedures (myelogram, cystogram, angiogram, and barium studies). The provider billed in the 
amount of $800 and the allowed amount is $166.92. This is less than the copayment amount. Therefore, results 
in the total cost sharing amount of $166.92. 
 
 You have been asked to pay a $166.92 copayment, which is less than the copayment for MRI. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for magnetic resonance imaging (MRI) on September 01, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for MRI and CT scan provided on July 14, 
2022, and August 12, 2022. 
 
You asked the Plan to waive the cost share for MRI and CT scan. You say that you were told this plan would 
cover all your needs and it does not. You say that you can't believe the Plan did not cover the total cost. The 
Plan denied your request. The Plan says this cost sharing was charged 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 20% 
coinsurance for Medicare-covered medical supply and $165 copayment for Medicare-covered radiological 
diagnostic services, not including x-rays, performed in a physicians office or at a free-standing facility (such 
as a radiology center or medical clinic). 
 
  You have been asked to pay $334.50 for an MRI and CT scan.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
July 14, 2022 MRI $386.07 $165 $165 
July 14, 2022 Supplies $6.00 20% $1.20 
July 14, 2022 Supplies $16.50 20% $3.30 
August 12, 2022 CT scan $189.16 $165 $165 
TOTAL:    $334.50 
 
The MRI and CT scan falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the cost share for MRI and CT scan provided on July 14, 2022, 
and August 12, 2022.