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

 
We decided that the Plan does not have to pay for office visit provided on April 25, 2022. 
 
You asked the Plan to pay for office visit. You say that you were sent to the clinic due to a latex allergy. You 
would like the Plan to reconsider the payment for this visit. 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 office visit provided on 
April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the routine eye exam provided on September 29, 2022. 
 
You asked the Plan to pay for the routine eye exam. You say that you should not be billed for a routine eye 
exam. You say you should not be billed for a service that was not routine based. The Plan denied your request. 
The Plan says that the service was denied as the benefit has been exhausted. 
 
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 when once per calendar year. 
 
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. We looked at the file and the Plan's rules. Specifically, the Plan did not submit 
documentation showing that the Plan paid for a routine eye exam on May 23, 2022. Therefore, we decided that 
the Plan has to pay for the routine eye exam provided on September 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an eyecare office visit (99214) provided on 
September 13, 2022. 
 
You asked the Plan to reduce the copayment for an eyecare office visit (99214). You say that you have 
glaucoma and should not have to pay a $50 copayment everytime you go in for a regular check up for the eyes. 
You also say that your regular eye examination should be $15. 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 $50 
copayment for Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of 
the eye. 
 
You have been asked to pay a $50 copayment for an eyecare office visit (99214). This item/service falls within 
the Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye 
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 reduce the copayment for an eyecare office visit (99214) 
provided on September 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the heart 
(75561). 
 
You asked the Plan to pre-approve an MRI of the heart. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the requested 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 an MRI of the heart. Our reviewer says 
that the service is not medically appropriate and necessary in this enrollees clinical management. Our 
physician reviewer found no recent cardiac testing has been performed, including echocardiogram or nuclear 
stress testing. The physician is requesting this study as a first-line diagnostic test. Guidelines do not support a 
need for cardiac MRI in this setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve magnetic resonance imaging (MRI) of the heart (75561).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Irinotecan Liposome injection (J9205) provided on August 1, 2022. 
 
You asked the Plan to pay for the Irinotecan Liposome injection. The Plan denied your request. The Plan says 
that if photos are a part of the clinical records, send copies since originals will not be returned. The Plan also 
says additional information is needed in order to consider this charge. 
 
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 records do not support that additional information is needed to support this 
charge. This means that the Plan has not provided a valid reason for denying payment of the Irinotecan 
Liposome injection. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, 
the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to 
pay for the Irinotecan Liposome injection (J9205) provided on August 1, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on 
August 25, 2022. 
 
You asked the Plan to pay for the ultrasound of the abdominal aorta. You say that you would like this claim to 
be reprocessed for payment. The Plan denied your request. The Plan says the diagnosis code billed with this 
claim does not indicate that the coverage criteria have been met. 
 
The Plan follows Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for AAA for beneficiaries who meet the criteria listed in the Medicare rules section of this letter. The 
rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, 
are not covered. 
 
The test at issue in this appeal, the ultrasound of the abdominal aorta, was requested solely for screening 
purposes. The record shows that this claim was billed with diagnosis code Z13.6, defined as Encounter for 
screening for cardiovascular disorder. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) 
provided on August 25, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport 
provided on December 23, 2021. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the requested ambulance transport. The Plan denied your 
request. The Plan says that there was insufficient information to determine if other coverage exists. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan must follow Medicare rules. The 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. 
 
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 did nothing to show us that these services are the liability 
of a different insurer, or that they are secondary payers for this claim. They also  didnt specify who the other 
insurer was, and they didnt make any clear efforts to have the claim submitted to the other insurer. There is 
also no evidence that the Plan has met its obligation in regard to coordination of benefits. Therefore, we 
decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport provided on 
December 23, 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 pre-approve the office visit. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve the office visit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from August 13, 2022, 
to August 15, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you did not self-administer the drugs. 
You also say that the drugs were dispensed and administered to you by the hospital staff. The Plan denied your 
request. The Plan says self-administered drugs are not Part B covered. 
 
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 self-administered drugs 
provided from August 13, 2022, to August 15, 2022.  
 Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from August 22, 2021, to 
August 24, 2021. 
 
You asked the Plan to pay for inpatient hospital services. You say that you are of the opinion that the services 
provided to this enrollee were medically reasonable and necessary both for the treatment of the enrollee's 
condition and on an inpatient hospital basis. The Plan denied your request. The Plan says this was not 
medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient hospital services have been 
met. The record shows no medical records have been submitted. Without the medical records, we cannot 
determine if there was medical necessity. Therefore, we decided that the Plan does not have to pay for inpatient 
hospital services provided from August 22, 2021, to August 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from June 14, 2021, to 
June 15, 2021. 
 
You asked the Plan to pay for inpatient hospital services. You say that the member was seen at the hospital and 
resides in a nursing facility. The Plan denied your request. The Plan says the service or item in question is not 
covered under the member's contract because there is an identity theft alert. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for inpatient hospital services was not filed until October 2, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital services provided from June 14, 2021, to June 
15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital lab services and an 
electrocardiogram (ECG) provided on September 23, 2022. 
 
You asked the Plan to waive the copayment for the lab services and the electrocardiogram (ECG). You say that 
it was not your choice to go to a different location for these services. 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 $5 
copayment for bloodwork processed at an independent lab, and a $50 copayment for diagnostic procedures and 
tests done at any location besides a physicians office. 
 
 
 You have been asked to pay a $5 copayment for the lab services. This item/service falls within the outpatient 
hospital services category. You have also been asked to pay a $50 copayment for the electrocardiogram (ECG). 
This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. You have been asked to pay a total cost-share of $55 for the lab services and the electrocardiogram 
(ECG). This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the outpatient hospital lab services and an 
electrocardiogram (ECG) provided on September 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray provided on August 26, 
2022. 
 
You asked the Plan to waive the copayment for the chest x-ray. You say that you don't have copayments for 
this service. 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 each outpatient x-ray. 
 
You have been asked to pay a $35 copayment for the chest x-ray. 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 the chest x-ray provided on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eyewear (V2025, V2781, V2750, V2784) 
provided on September 30, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for the routine eyewear. You say that this provider was cheaper than the in-network 
providers. The Plan denied your request. The Plan says your eyewear is not covered because it was provided 
OON. 
 
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 when provided by a provider in the Plans routine vision network. 
 
We looked at the file and the Plan's rules. The requested provider in this case is not a network provider in the 
Plans routine vision network. 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 items/services. Based on this information, we decided that the 
Plan's rules for coverage of the routine eyewear have not been met. Therefore, we decided that the Plan does 
not have to pay for the routine eyewear (V2025, V2781, V2750, V2784) provided on September 30, 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 CT scan provided on October 11, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are disputing the share 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 a $270 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $270 copayment for CT scan. 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 CT scan provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on September 8, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on September 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for CT scan provided on September 15, 2022. 
 
You asked the Plan to reduce the copayment for CT scan. You say that your cost share amount should be 
$40.00, you cannot afford the billed amount. 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 $250 
copayment for advanced imaging service (MRI, CT, PET scans, and stress tests).  
 
You have been asked to pay $201.67, which is less than the standard $250 copayment for a CT scan. The 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 reduce the copayment for CT scan provided on September 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 17, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
husband called the fire department because he thought you were having a heart attack. You also say that the 
fireman told you husband you would get a bill but to say it was an emergency, which it was. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 17, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on September 17, 2022.