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

 
We decided that the Plan does not have to pre-approve an office visit with an oncology specialist for a second 
opinion, to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit with a specialist. You say that you have been waiting for an 
appointment for your chemotherapy treatment. The provider has cancelled twice because you had a low blood 
count. You have tried working with the Plan and it has become too much for you especially in dealing with 
your illness. You would like reconsideration to see an OON provider. The Plan denied your request. The Plan 
says you are eligible for an in-Plan second opinion. You must use an in-network provider to receive services. 
The Plan also says there are in-network providers available for this 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 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 
an office visit with an oncology specialist for a second opinion, to be provided by an out-of-network (OON) 
provider.  
 
Your complaint about your current provider and the cancellation of your chemotherapy treatment 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures. 
 
You asked the Plan to pre-approve dentures. The Plan denied your request. The Plan says the enrollee has 
exceeded the frequency limitation set. 
 
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 coverage for dentures is limited to 
one set every five plan years. The records show that you received coverage for dentures on November 22, 
2019. This means that it has not been five years since the last set of dentures was covered. Therefore, we 
decided that the Plan does not have to pre-approve dentures.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 10, 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 procedure code 81015 is not separately payable. 
 
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 81015 
is a column II code to column I code 81003 with a modifier indicator of 0.  
 
 
 
 The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
December 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral appliance rendered on November 23, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 oral appliance rendered on November 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lynparza for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 pre-approve Lynparza for the enrollee.  
 
Benefits for this drug 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammography on January 14, 2022. 
 
You asked the Plan to waive the copayment for a mammography. You say that you would like to appeal the 
cost share. 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 a $180 
copayment for a mammography. However, since the allowed amount is less than the applicable cost share, the 
total allowed amount of $162.23 charged is the member's responsibility. 
 
You have been asked to pay a $180 copayment for a mammography. A mammography 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 mammography on January 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiogram (TTE) rendered on 
September 8, 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 procedure code 93350 is not separately payable.  
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 93350 
is a column II code to column I code 93306. 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 the transthoracic echocardiogram (TTE) rendered on September 
8, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost for the services provided on September 27, 2021. We decided 
that the Plan does not have to waive the copayments for the office visit and outpatient clinic visit provided on 
December 13, 2021.  
 
You asked the Plan to waive the copayments for the office visits. You say that there is no charge for annual 
wellness visits. The Plan says no copayment applied to the annual wellness visit and the remaining copayments 
were applied correctly. 
 
We decided that the Plan has to waive the cost for the services provided on September 27, 2021.  
 
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 did not submit an Explanation of Benefits or claim form to confirm 
what services were billed on September 27, 2021. This means that we cannot determine the cost you are being 
asked to pay is correct or justified by the Plan contract. 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 waive the cost for the services provided on September 27, 2021.  
 
We also decided that the Plan does not have to waive the copayments for the office visit and outpatient 
clinic visit provided on December 13, 2021. 
 
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 each Medicare-covered primary care provider visit. Therefore, we decided that the Plan does not 
have to waive the copayments for the office visit and outpatient clinic visit provided on December 13, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three (3) units of lung perfusion imaging (78580) provided 
on October 22, 2021. 
 
You asked the Plan to pay for three (3) units of lung perfusion imaging. You say that the number of units of 
this service were medically necessary and were billed appropriately. The Plan denied your request. The Plan 
says the documentation provided does not support the number of units billed. In addition, it would generally be 
inappropriate to provide more than one unit of 78580 except in certain circumstances. The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 three (3) units of lung perfusion imaging 
Our reviewer says that the number of units billed are not supported in this case. Our physician reviewer found 
the medical record documents a lung perfusion scan, which supports one (1) unit. The additional two (2) units 
billed cannot be verified in this case with the documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of three (3) units of lung perfusion imaging have not been met. Therefore, we 
decided that the Plan does not have to pay for three (3) units of lung perfusion imaging (78580) provided on 
October 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a PET scan. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if medically necessary and reasonable, Medicare 
will cover one Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan to determine the initial 
level of cancer treatment needed for an enrollee. Therefore, we decided that the Plan does not have to pre-
approve a PET scan. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hearing aid, digital, binaural, behind the ear (V5261) 
provided February 11, 2022. 
 
You asked the Plan to pre-approve the hearing aids. You say that you would like the Plan to pay their share of 
the cost. The Plan denied your request. The Plan says the Plan has covered the full $500 allowance for the 
hearing aids, and no additional payment is due. 
 
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 up to a $500 maximum benefit coverage amount.  
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that the $500 benefit has 
been applied to your hearing aids. You have been asked to pay the cost above this amount. 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 pre-approve the hearing aid, digital, binaural, behind the ear (V5261) provided February 
11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the coinsurance for durvalumab injections provided 
on February 7, 2022, and February 22, 2022. 
 
You asked the Plan to waive or reduce the coinsurance for the injections. You say that the enrollee could not 
afford the high copayments. The Plan denied your request. The Plan says the correct coinsurance was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Part B chemotherapy drugs. 
 
Drug Allowed Amount 20% Coinsurance 
Durvalumab  February 7, 2022 $3,842.95 $768.59 
 $768.59 $153.72 
Durvalumab  February 22, 2022 $4,611.54 $922.31 
Total:  $1,844.62 The enrollee was asked to pay $1,844.62, which is 20% of the allowed amount for the injections. The injections 
fall within the Medicare Part B Prescription Drugs benefit category. This means that the enrollee was 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 or 
reduce the coinsurance for durvalumab injections provided on February 7, 2022, and February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eyeglasses (V2020, V2203, V2781, V2755, V2750) 
provided on February 11, 2022. 
 
You asked the Plan to pay more for eyeglasses. You say that these eyeglasses were provided following your 
cataract surgery, and you feel the Plan should cover a greater cost. You say you have already paid $273.95 for 
these eyeglasses, and now you are being billed an additional $15. The Plan denied your request. The Plan says 
this claim was processed correctly, and your share of the cost was assessed in accordance with your contract. 
 
Although you state that these eyeglasses were provided following a cataract surgery, there is no documentation 
in the provided record to show that you have had cataract surgery. The diagnoses billed on this claim are 
presbyopia (H52.4) and regular astigmatism, bilateral (H52.223) which are both disorders of refraction and 
accommodation which would require routine corrective eyewear. 
 
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 routine lenses in full once every two years and will pay up to $200 every two years 
for either eyeglass frames or contact lenses. Some upgrades are permitted with additional cost-sharing. 
 
We looked at the file and the Plan's rules. The record shows that the eyeglasses purchased on the date in 
question included standard frames (V2020), bifocal lenses (V2203), progressive lenses (V2781), UV coating 
(V2755) and anti-reflective coating (V2750). The provider billed a total of $652.95 for all five components.  
 
The retail price of the frames was $343.95. The Plan paid the full $200 frame allowance, and you are 
responsible for the remaining $143.95 for the frames. The cost of the bifocal lenses with a progressive lens 
upgrade was $189. The Plan paid $124, and you are responsible for a $65 copayment for the progressive 
upgrade as stated in the contract. The total cost of the UV coating was $20, for which you are responsible for a 
$15 copayment based on your contract with the Plan. Lastly, these eyeglasses have anti-reflective coating. The 
provider billed $100 for this upgrade; you are responsible for a $65 copayment for standard-anti-reflective 
coating, and the Plan paid the remaining cost.  
 
Your total responsibility, including the cost of your copayments and the amount in excess of your benefits 
frame allowance, is $288.95 ($143.95 (frame cost which exceeded allowance) + $65 (progressive upgrade) + 
$65 (anti-reflective upgrade) + $15 (UV coating) = $288.95). 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 pay an additional 
amount for the eyeglasses (V2020, V2203, V2781, V2755, V2750) provided on February 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you were admitted for surgical management of olecranon fracture after a fall. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. In this case, you do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. In conclusion, there is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 28, 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 the laboratory services provided on December 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on 
November 23, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you feel this charge should 
be 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 $250 
copayment for each one -way Medicare covered ground transportation service.  
 
You have been asked to pay $250 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance 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 ambulance transport 
provided on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 21, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments provided by these providers. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the 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 a domiciliary or rest home visit provided on 
October 21, 2021, by an out-of-network (OON) provider.