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

 
We decided that the Plan does not have to reduce the copayment for the back injection provided on June 20, 
2022. 
 
You asked the Plan to reduce the copayment for the back injection. You say that you had the same injection in 
March and only paid $55. 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 $250 
copayment for outpatient procedures and services performed in an outpatient hospital or ambulatory surgical 
center. 
 
You have been asked to pay a $250 copayment for the back injection. This item/service falls within the 
outpatient procedures and services performed in an outpatient hospital or ambulatory surgical center 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 the back injection provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 01, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a diabetic eye 
exam and should not have 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 $35 
copayment for physician/practitioner services, including doctors office visits (specialist visits). 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits (specialist 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 the specialist office visit provided on November 01, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ,drug testing provided on June 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that you do not directly see the patients and you rely on 
providers and clinics to verify network status. The Plan denied your request. The Plan says the services were 
not authorized by a network provider. 
 
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 ,drug testing provided on June 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 a diagnostic imaging provided on June 6, 
2022. 
 
You asked the Plan to waive the copayment for a diagnostic imaging. You say that you would like this 
copayment reconsidered. 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 $200 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $126.97, which is less than the original copayment of $200 for diagnostic imaging. 
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 a diagnostic imaging provided on June 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on 
March 19, 2022, to March 23, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you cannot afford the 
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 $1,180 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,180 copayment for the inpatient hospital care. This item/service falls within 
the inpatient hospital care 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. Per the EOC, there is a $295 copayment for days 1-6 of inpatient care. You were in the 
hospital for 4 days from March 19, 2022, to March 23, 2022. The total for the 4 days is $1,180. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on March 
19, 2022, to March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic procedure provided on June 10, 
2022. 
 
You asked the Plan to waive the copayment for diagnostic procedure. You say that the copayment is wrong and 
you shouldnt have to pay this. 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 $36.49 
copayment for diagnostic procedures or tests in a doctors office. 
 
You have been asked to pay a $36.49 copayment for diagnostic procedure. This item/service falls within the 
diagnostic procedures or tests in a doctors 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 diagnostic procedure provided on June 10, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for insertion of non-tunneled centrally inserted central venous catheter 
(procedure code 36556) provided to the enrollee on October 9, 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 support the services billed. 
 
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 36556 is Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older. 
 
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 documentation supports coverage 
of the code as billed.  There is satisfactory documentation that the patient underwent a non-tunneled right 
internal jugular central venous catheter placement as described in a formal procedure note. The health plan had 
initially denied coverage indicating there was no medical record documentation of the location of the catheter 
tip. However, there is documentation on 10/9/2021  Chest x-ray at 3:55 AM (the same day as the catheter 
placement) that the central venous catheter tip projects over the right atrium. This is consistent with central 
venous placement. 
 
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 
insertion of non-tunneled centrally inserted central venous catheter (procedure code 36556) provided to the 
enrollee on October 9, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections of 800 units every 90 days. 
 
You asked the Plan to pre-approve the requested dosage of Botox. You say that the enrollee would benefit from 
the requested dosage. The Plan denied your request. The Plan says the requested dosage is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the requested dosage of Botox. Our 
reviewer says that the requested dosage of Botox treatment is not considered medically reasonable and 
necessary. Our physician reviewer found the enrollee is a male with a diagnosis of multiple sclerosis with 
spasticity.  Based on the medical records provided and the Medicare-approved major drug compendia there is 
no documentation that the Botox injections 800 units per 90 days at issue in this case meet all Medicare criteria 
for medically reasonable and necessary for the patient. None of the Medicare-approved major drug compendia 
support the dosage of 800 units per 90 days for Botox injections for treatment of multiple sclerosis with 
spasticity. The compendia do not support this dosage as safe and effective. 
 
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 requested dosage of Botox have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Botox injections of 800 units every 90 days.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist telehealth visit provided on 
February 15, 2022. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you should not have 
to pay since you had to wait on the line for two hours. 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 (specialist telehealth visits). 
 
You have been asked to pay a $35 copayment for the specialist telehealth visit. This item/service falls within 
the physician/practitioner services, including doctors office visits (specialist telehealth 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 the specialist telehealth visit provided on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator (AED) 
vest provided on April 03, 2022. 
 
You asked the Plan to waive the coinsurance for the automatic external defibrillator (AED) vest. You say that 
you feel insurance should pay the bill. 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 durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for the automatic external defibrillator (AED) vest. This 
item/service 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. The allowed amount for 
the AED device is $2,931.45, and the 20% coinsurance applied is $586.29. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the automatic external defibrillator (AED) vest provided on April 
03, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physical therapy on February 18, 2022, to 
March 04, 2022. 
 
You asked the Plan to waive the deductible for physical therapy. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to Outpatient rehabilitation services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible which applies to Outpatient rehabilitation services. This cost sharing is a contractual obligation 
that had not been met at the time physical therapy was received on February 18, 2022, to March 4, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for physical therapy on February 18, 
2022, to March 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) for tooth #18 provided by a participating 
provider. 
 
You asked the Plan to pay for a crown. You say that a crown is medically necessary. The Plan denied your 
request. The Plan says these services have been correctly denied. 
 
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 crown 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 pay for a crown. Our reviewer says that the 
requested procedure would not be considered reasonable and necessary. Our physician reviewer found there 
does not appear to be sufficient missing structure as to require a full coverage crown to restore the tooth and 
maintain it in function. 
 
  
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 crown have not been met. Therefore, we decided that the Plan does not have 
to pay for a crown (D2740) for tooth #18 provided by a participating provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room on June 7th, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you were never seen in the 
emergency room. 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 $120 
copayment for emergency care.  
 
You have been asked to pay the allowed amount of $86.72, which is less than the $120 copayment for 
emergency care. This item/service falls within the emergency care 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 emergency room on June 7th, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prosthetic items (L5673, L5620, L5910, L5637, L8440) 
provided on May 17, 2022. 
 
You asked the Plan to pay for the prosthetic items. You say that these pieces were custom made for the 
enrollee. You say that with salvage claims, you bill for the enrollee's date of death. You say that these should 
be paid accordingly. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the prosthetic items (L5673, L5620, L5910, L5637, L8440) 
provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hi-index lenses (V2783) and polarized lenses (V2762) 
provided on June 2, 2022. 
 
You asked the Plan to pay for the hi-index and polarized lenses. You say that you have Astigmatism, and this is 
the only type of lens that work for you. The Plan denied your request. The Plan says these lenses are not 
covered under your plan and are considered outside the benefit coverage. 
 
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 standard CR29 single, bifocal, trifocal, and standard progressive lenses. 
 
 
 We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we 
decided that the Plan's rules for coverage of the hi-index and polarized lenses have not been met. Therefore, we 
decided that the Plan does not have to pay for the hi-index lenses (V2783) and polarized lenses (V2762) 
provided on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473) provided by 
a participating provider. 
 
You asked the Plan to pre-approve the removal of torus mandibularis. You say that you would like the Plan to 
approve these services. The Plan denied your request. The Plan says D7473 is not a covered benefit. 
 
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 the 
removal of torus mandibularis (D7473) provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this equipment is necessary for your 
medical condition. The Plan denied your request. The Plan says Medicare does not cover ventilators used in 
this way and your needs could be met by a bilevel positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide continuous or bilevel 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered. Based 
on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on 
June 10, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you were able to pay less from the out-of-network 
provider. You say it does not make sense to use the in-network provider when you can save money out-of-
network. The Plan denied your request. The Plan says there is no coverage if hearing aids are received from an 
out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only There is no coverage if hearing aids, or related services are received from an out-of-network 
provider. 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 hearing aids.  
 
We looked at this the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the hearing aids were not provided by a network 
provider. Therefore, we decided that the Plan does not have to pay for the hearing aids provided by an out-of-
network provider on June 10, 2022.