Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bilateral wrist-hand orthosis rendered on March 1, 
2022. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services were not medically necessary. 
 
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 these services. Our reviewer says that 
the services were not medically necessary. Our physician reviewer found the submitted records include a face-
to-face medical visit note dated December 18, 2021 that documents left hand pain and numbness but as best as 
can be deciphered from the handwritten note there was no documentation that bilateral non-torsion joint, wrist, 
hand orthoses were needed or ordered. The services were not reasonable or medically necessary based on the 
submitted documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bilateral wrist-hand orthosis rendered on March 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a nerve block. 
 
You asked the Plan to pre-approve a nerve block. You say that the services are necessary. The Plan denied your 
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 nerve block. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the health plan is using criteria for complex regional pain syndrome rather than for centrally 
mediated pain. A sympathetic nerve block is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a nerve block have been met. Therefore, we decided that the Plan has to pre-
approve a nerve block.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for electrical osteogenesis stimulator provided 
on March 31, 2021. 
 
You asked the Plan to waive the coinsurance for electrical osteogenesis stimulator. You say that the charge is 
excessive and if you would have known how much it would cost you never would have received one. The Plan 
denied your request. The Plan says the coinsurance applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment.  
 
 
 
 
 You have been asked to pay $906.02 which is 20% of the allowed amount for electrical osteogenesis 
stimulator.  The allowed amount is $4,530.12 (20% x $4,530.12= $906.02). Electrical osteogenesis stimulator 
falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for electrical osteogenesis stimulator provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with a specialist for a second opinion 
(992005, 99449, 99215, 52000, 88321, 88323, 88325) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits with a specialist. You say that you are requesting a second 
opinion and treatment with the requested provider as you were told they are experts in your type of cancer. You 
also say the providers you were seeing are not experienced with Mesothelioma cancer in the early stages. The 
Plan denied your request. The Plan says you must use network providers to get your medical care and 
services. Benefits are available with participating providers in the Plan's network. The Plan has several 
oncologists as well as hospitals with specialty physicians available in your area. 
 
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 
office visits with a specialist for a second opinion (992005, 99449, 99215, 52000, 88321, 88323, 88325) to be 
provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient speech therapy services, a 
cardiovascular stress test, and a laryngoscopy procedure to examine the larynx, or voice box, provided from 
November 22, 2021, to December 20, 2021. 
 
You asked the Plan to waive the copayment for speech therapy services and diagnostic testing. You say that 
you contracted COVID-19 in November 2020 and have had post-COVID symptoms. You say you were 
examined by the post-COVID clinic and subsequently referred to several specialists. You say you contacted the 
Plan and a representative told you COVID-related procedures and cost-shares are fully covered. You say the 
copayments should be paid for by the Plan as you were previously advised.  The Plan denied your request. The 
Plan says the copayments were applied correctly. The Plan says the medical claim from your treating physician 
does not indicate a COVID-19 diagnostic history. 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 $95 
copayment for diagnostic procedures and tests and a $40 copayment for speech therapy provided in an 
outpatient hospital setting.  
 
You have been asked to pay a $295 copayment for speech therapy services and diagnostic testing. Speech 
therapy services fall within the Outpatient Rehabilitation Services benefit category. Additionally, diagnostic 
testing falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. See 
below for dates of service with corresponding copayment amounts. 
 
November 22, 2021: $40 copayment (speech therapy services) 
November 29, 2021: $40 copayment (speech therapy services)  
December 6, 2021: $40 copayment (speech therapy services) 
December 13, 2021: $95 copayment (cardiovascular stress test) 
December 20, 2021: $40 copayment (laryngoscopy) + $40 copayment (speech therapy services) 
 
Total Copayment: $40  5 services = $200 + $95 = $295 
 
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 outpatient speech therapy services, a cardiovascular stress 
test, and a laryngoscopy procedure to examine the larynx, or voice box, provided from November 22, 2021, to 
December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the 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 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 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on April 28, 2022, by an out-
of-network provider. 
 You asked the Plan to pay for the chiropractic services. You say that the enrollee is entitled to all Medicare 
approved services. The Plan denied your request. The Plan says there is no referring provider involved in these 
services and the plan did not authorize any service. 
 
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 chiropractic services provided on April 28, 2022, 
by an out-of-network provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for additional mammography services provided to the enrollee on 
November 30, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not indicate that two separate services were performed or supported. 
 
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, the CPT Code Manual definition of 
code 77065 is "Diagnostic mammography, including computer-aided detection (CAD) when performed; 
unilateral." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee had a diagnostic 
unilateral 2D mammogram - CPT 77065 - on 11/30/21, followed by a diagnostic unilateral study using digital 
breast tomosynthesis - CPT 77052. These codes are usually bundled together in one report, but in this case, two 
separate reports were issued. This is acceptable, per the CPT manual. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
additional mammography services provided to the enrollee on November 30, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on April 18, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the eye refraction 
that was provided is not a covered benefit since it was medical vision check (Fourth (trochlear) nerve palsy, 
unspecified eye, hypermetropia, bilateral). Eye refractions are only covered by your Plan if performed by a 
participating vision provider and performed as a routine screening per your 2022 Evidence of Coverage, 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
 
 
 
 
 
 
 
 We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on April 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for imaging supplies provided on March 22, 
2022. 
 
You asked the Plan to waive the coinsurance for imaging supplies. You say that the information from the plan 
is misleading. 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 covered medical supply. The allowed amount of this scan is $5,745.60 resulting in a 
coinsurance amount of $1,149.12. 
 
You have been asked to pay a 20% coinsurance for each covered medical supply. Imaging supplies 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 coinsurance for imaging supplies provided on March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotic devices (L3170 and L1971) provided on 
February 22, 2022. 
 
You asked the Plan to pay for the orthotic devices. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says required documentation is missing for 
payment of this claim. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support the medical necessity for the supplies 
provided in this case. Specifically, the medical records do not indicate the ordering provider discussed the 
medical need for the ordered equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the orthotic devices (L3170 and L1971) provided on February 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan on 
January 6, 2022. 
 
You asked the Plan to waive the copayment for a computerized tomography (CT) scan. You say that you would 
like to appeal the cost share. The Plan denied your request. The Plan says the copayment of $178.17 you are 
being charged is correct since the amount due is under the normal $180 copayment 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $180 copayment for a computerized tomography (CT) scan.  
 
The enrollee has been asked to pay a $180 copayment for a computerized tomography (CT) scan. A 
computerized tomography (CT) scan falls within the Outpatient hospital services benefit category. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for a computerized tomography (CT) scan on January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on January 24, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and 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 wound care services provided on January 24, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81206, 81210, 81235, 
81272, 81275, 81276, 81292, 81301, 81311, 81321 provided January 26, 2022.  
You asked the Plan to pay for the laboratory services. You say that Please see attached documents. The Plan 
denied your request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The Plan verified after outreach to the referring providers office 
indicated on the referral, that the doctor did not write the order for the genetic testing. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 81206, 81210, 
81235, 81272, 81275, 81276, 81292, 81301, 81311, 81321 provided January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for an eye specialist office 
visit, eye imaging, and bevacizumab injection provided on February 1, 2022. 
 
You asked the Plan to waive the copayments and coinsurance for the office visit, imaging, and injection. You 
say that you feel the services were billed incorrectly as out-of-network. The Plan denied your request. The Plan 
says the correct copayments and coinsurance were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each exam to treat an eye condition. 
 
Your contract with the Plan also clearly says that you must pay a $65 copayment for each diagnostic procedure 
or test at a network doctor's office. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the Vision Care 
benefit category. You have also been asked to pay $40.96 for the imaging, which is less than the $65 
copayment. The imaging falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. You have also been asked to pay $13.57 for the injection, which is 20% of the allowed 
amount ($67.86 allowed amount x 20% coinsurance = $13.57). The injection falls within the Medicare Part B 
Prescription Drugs benefit category. The total for all services is $89.53. 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 and coinsurance for an eye specialist office visit, eye imaging, and bevacizumab injection 
provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the first periapical x-ray (D0220), additional periapical x-rays (D0230 x 
4), bitewing x-rays (D0274), and a panoramic x-ray (D0330) provided on March 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says that codes D0220, D0230, and D0274 were bundled and paid as a 
complete series. The Plan also says that code D0330 is not permitted on the same date of service as the other 
procedures billed. 
 
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. The Plan showed the dental services are covered but 
there is no indication that the benefits have been exhausted. There is also no evidence that the Plan made 
payment on the codes as they were billed to the Plan. Therefore, we decided that the Plan has to pay for the 
first periapical x-ray (D0220), additional periapical x-rays (D0230 x 4), bitewing x-rays (D0274), and a 
panoramic x-ray (D0330) provided on March 9, 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.