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

 
We decided that the Plan does not have to waive the copayment for urgently needed services on April 18, 2022. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $30 
copayment for each Medicare-covered urgent care facility visit. Urgently needed services are provided to treat 
a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. 
Urgently needed services may be furnished by network providers or by out-of-network providers when network 
providers are temporarily unavailable or inaccessible. 
 
 
 
 
 You have been asked to pay a $30 copayment for urgently needed services. Urgently needed services fall 
within the Urgently needed 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 
urgently needed services on April 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
lumbar spine provided on March 19, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that the test was inconclusive due to provider 
error. You say that you should not be responsible for the cost share. 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 $150 
copayment per day, per provider, for diagnostic radiology services, including MRI's.  
 
You have been asked to pay a $150 copayment for the MRI. The MRI 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 a magnetic resonance imaging (MRI) of the lumbar spine provided on March 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Accu-Check guide test strips to be provided by a 
non 
 
You asked the Plan to pre-approve the diabetic supplies. You say that you are appealing the denial of the 
approval for Accu-Check test strips. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage for a non-preferred diabetic supply bought at a pharmacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. You may speak with your provider to ask them to request the preferred brand or to request an order of the non-preferred brand from a DME supplier. It will then be covered 
at the DME co-payment level per the Evidence of Coverage. Based on this information, we decided that 
Medicare rules for coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Accu-Check guide test strips to be provided by a non
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says you 
have used 18 one-way trips that are covered by your plan for the year 2022. The Plan also says that additional 
trips in excess of 18 one-way trips are not covered by the health plan. 
 
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 18 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 transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested services 
are a medical necessity for your kidney dialysis. The Plan denied your request. The Plan says the routine 
transportation benefit has been exhausted for the year. 
 
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 48 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 routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on April 
22, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that the visit should be considered 
in-network. 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 $40 
copayment for specialist office visits.  
 
You have been asked to pay a $40 copayment for the specialist visit, which is the in-network rate. The 
specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided on April 22, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown (D6066). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says an implant supported crown (D6066) is not covered by 
your dental 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 pre-approve an 
implant supported crown (D6066).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 17, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient domiciliary or rest home visit (99336) 
transitional care management (99496) provided on February 23, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that this enrollee is residing at the 
nursing facility and an authorization should be on file for their stay. You have attached the medical records 
which supports the services. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 established patient domiciliary or rest home 
visit (99336) transitional care management (99496) provided on February 23, 2022 by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRI provided on January 13, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you are not financially able to pay these 
bills and need them covered. The Plan denied your request. The Plan says the copayment 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 $200 
copayment for all other diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay $200 copayment for MRI. MRIs fall within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
MRI provided on January 13, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the service billed with code 93306 for date of service February 15, 
2022. 
 
You asked the Plan to pay for procedure code 93306. You say that this service was necessary and was billed 
appropriately. The Plan denied your request. The Plan says that the payment for this service is included in the 
payment for another service. 
 
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 the original claim(s) or any information 
to show how this service was billed or whether it was billed with other services which would supersede 
payment of this service. In addition, the two codes mentioned in the Plans narrative (99204, 99213), which are 
not proven as billed without this information, also do not include payment for 93306 which means the service 
at issue would be separately billable/payable. The Plans denial is not substantiated in this case. Therefore, we 
decided that the Plan has to pay for the service billed with code 93306 for date of service February 15, 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 pre-approve abutment supported crowns on tooth #9, 12, 18, 19, 29, 
30, and 31 (D6063) and implant supported crowns on tooth #9, 12, 18, 19, 29, 30, and 31 (D6065). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot pay for these services out of 
pocket. The Plan denied your request. The Plan says abutment supported crowns (D6063) and implant 
supported crowns (D6065) are not covered by your dental 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 pre-approve 
abutment supported crowns on tooth #9, 12, 18, 19, 29, 30, and 31 (D6063) and implant supported crowns on 
tooth #9, 12, 18, 19, 29, 30, and 31 (D6065).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network primary care office visit 
provided on April 14, 2022. 
 
You asked the Plan to waive the copayment for an in-network office visit. You say that this should have been a 
wellness visit and should not have a copayment. 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 $10 
copayment for primary care physicians office.  
 
You have been asked to pay a $10 copayment for an in-network primary care office visit. An in-network 
primary care office visit falls within Primary Care Physicians Office 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 primary care office visit provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the lens, polycarbonate or equal, any 
index, per lens (V2784) and deluxe frames (V2025) provided November 30, 2021.  
You asked the Plan to provide additional payment for the routine eyewear. You say that you were overcharged 
for your eyewear. The Plan denied your request. The Plan says the claim has processed correctly, and no 
additional payment is due. 
 
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 up to a $150 allowance.   
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that the full $150 
allowance was applied towards your routine eyewear. You have been asked to pay a $10 copayment plus the 
difference between the Plan allowance and the total cost charged for the eyewear. This means you have been 
asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does 
not have to provide additional payment for the lens, polycarbonate or equal, any index, per lens (V2784) and 
deluxe frames (V2025) provided November 30, 2021.  
 
Your complaint about the quality of providers in the Plans network is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lower extremity joint, 
without contrast material (73721). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that this service is not medically necessary. 
 
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 this service. Our reviewer says that this 
service is medically necessary. Our physician reviewer found that at issue is whether an MRI of the ankle for 
the enrollee is a covered service under Medicare rules. The rules say that MRIs are covered when medically 
necessary and reasonable for the diagnosis or treatment of the specific patient involved. In this case, the record 
indicates that the enrollee suffered a fall approximately a month ago. The physical examination demonstrates 
significant ligamentous instability. The prescribing physician has addressed the likely failure of physical 
therapy prior to obtaining the requested study. The requested service is medically necessary and reasonable for 
the diagnosis and treatment for the enrollee's specific clinical condition at this time. The elements of the 
coverage criteria are satisfied. The requested service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance imaging (MRI) of the lower extremity joint, without contrast material (73721). 
  
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 pre-approve a microprocessor knee and an advanced foot for lower-
extremity prosthetics. 
 
You asked the Plan to pre-approve a microprocessor knee and an advanced foot. You say that the requested 
items are a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for 
coverage of the requested items have not been met. 
 The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain 
components/additions to the prosthesis is based on the enrollee's s potential functional abilities. 
 
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 microprocessor knee and an advanced 
foot. Our reviewer says that the requested additions to a prosthesis are not medically reasonable and necessary 
in this case. Our physician reviewer found that the provided records document that you are currently relying on 
a walker or wheelchair for mobility despite your present K1 level prosthesis and your amputation being more 
than a year ago. Records do not document that you have ever used a K2 or K3 level prosthesis, and given your 
comorbidities, including asthma, peripheral vascular disease, coronary artery disease and obesity, K3 level 
ambulation is not supported. 
 
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 microprocessor knee and an advanced foot have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a microprocessor knee and an advanced foot for lower-
extremity prosthetics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
November 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin three or more times per day or use an insulin pump. 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 pay for the continuous glucose monitor (CGM) supplies rendered on November 12, 2021.