Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
September 2, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you only went for a rapid COVID-19 
test and did not stay in a room. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit 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 an emergency room (ER) visit 
provided on September 2, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the out of network rates for the physician services (code 99222) 
provided on July 26, 2021. 
 
You asked the Plan to waive the out of network rates for the physician services. You say that the enrollee was 
on vacation and needed medical attention. You also say that this was a medical emergency, and out of network 
should not apply. The Plan denied your request. The Plan says that the enrollee was stabilized and the out of 
network cost sharing applied. The Plan says that the enrollee has been charged the correct cost sharing amount. 
 
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 medical records showing the enrollees condition was 
not, or was no longer, an emergency. Therefore, the Plan cannot cover the service at the out of network rate. 
 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 says that the doctors who give 
you emergency care are the ones who decide when you are stable, and the medical emergency is over. The 
contract also says that enrollees must pay a $200 copayment per day, for days 1-5, for in-network inpatient 
hospital care. The contract also says the in-network rate for physician services is $0 copayment while inpatient 
at a hospital. 
 
The Plan says the enrollee must pay 30% coinsurance for the physician services as part of an out of network 
hospital stay. Based on the plan contract, however, the enrollee cannot be asked to pay more than the in-
network rate of $0 copayment while inpatient at the hospital. We decided that the Plan has to waive the out of 
network rates for the physician services (code 99222) provided on July 26, 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: Favorable

 
We decided that the Plan has to reduce the copayment for a comprehensive hearing test performed on October 
12, 2021. 
 
You asked the Plan to reduce the copayment for the hearing test. You say that you paid a $40 copayment and 
the test should not be billed as an outpatient procedure. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay a $40 copayment for each diagnostic hearing and balance 
evaluation from a specialty care provider.  
 
The Plan says you must pay $134.44 for the hearing test. Based on the Plan contract, however, you cannot be 
asked to pay more than a $40 copayment for each diagnostic hearing and balance evaluation from a specialty 
care provider. Therefore, we decided that the Plan has to reduce the copayment for a comprehensive hearing 
test performed on October 12, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for an inpatient admission. 
 
You asked the Plan to provide coverage for the inpatient admission. You say that hospice will only cover 
patients with an illness related to chronic obstructive pulmonary disease (COPD). The Plan denied your 
request. The Plan says the requested service isn't covered by your Medicare Advantage Health Plan because 
you are enrolled in a hospice program. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
Your Medicare Hospice benefits will end on March 25, 2022. The services in question are before the end of 
that month. Therefore, we decided that the Plan does not have to provide coverage for an inpatient admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on May 14, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that the mid and lower tier hearing aids do not help you 
in most situations that is why you choose the Widex moment 440R, which is the brand offered to you. You say 
that you were never informed by this provider that this hearing aid was not a covered brand/product until you 
requested a receipt to send in for your refund. The Plan denied your request. The Plan says the hearing aids 
purchased do not fall within the copay structure. 
 
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.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids you purchased do not fall within 
the Plans hearing aid benefit copay structure. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services, medical examination provided on 
October 1, 2021. 
 
You asked the Plan to pay for the ophthalmological services, medical examination. You say that the member 
lives in an assisted living facility and the providers rely on facility staff to verify eligibility and obtain 
authorization from the patients insurance company. The Plan denied your request. The Plan says an 
authorization was not obtained prior to the services being rendered and the provider is not participating with the 
member's Plan. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for ophthalmological services, medical examination provided on 
October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat facet joint injections. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat facet injections are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of low back pain due to lumbar spondylosis. She has been treated with medical therapy including narcotics, an epidural 
steroid injection, a sacroiliac joint injection, and bilateral medical branch blocks (MBBs) at L4-L5 and L5-S1. 
The MBBs provided only 50 percent pain relief. The criteria for coverage are not met and the repeat injections 
are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on May 24, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you were only seen for a possible 
eye scratch and the provider informed you there would be no charge. 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 $20 
copayment for each exam to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $20 copayment for the eye exam. The eye exam falls within the Vision 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 an eye exam provided on May 
24, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 CDX testing provided to the enrollee on September 29, 
2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that the clinical documentation provided did not indicate that tissue-based testing was 
infeasible, or that it has already been completed and did not show any actionable mutations. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the Food and Drug Administration has approved Guardant360, a liquid biopsy companion diagnostic for 
tumor mutation profiling or comprehensive genomic profiling to identify patients with locally advanced or 
metastatic non-small cell lung cancer who have a KRAS G12C mutation and may benefit from sotorasib. The 
review has determined that the enrollee needed the testing in this case. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
Guardant360 CDX testing provided to the enrollee on September 29, 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 waive the copayment for a specialist office visit provided on October 
18, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you feel that your 
maximum out-of-pocket (MOOP) expenses had bet met previously. 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 $35 
copayment for each specialist visit.  
 
You have been asked to pay $28.53 for the specialist office visit. The specialist office visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. At the time this claim was submitted to and processed by the Plan, your MOOP had not been fulfilled. Please note that the order in which 
cost sharing is applied to your MOOP is dependent on how and when the billing offices submit claims to the 
Plan. 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 October 18, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (procedure code 76497) provided to the 
enrollee on August 17, 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 there is a more appropriate code to use. 
 
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 76497 is "Unlisted computed tomography procedure (eg, 
diagnostic, interventional)." 
 
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 computed tomography angiography 
(CTA) of the best is usually billed as CPT 71275, not the utilized code CPT 76497. 
 
 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 not been met. Therefore, we decided that the Plan does not 
have to pay for radiology services (procedure code 76497) provided to the enrollee on August 17, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to waive the out of network rates for the physician services (code 99232, 99231, 
and 99223) provided from July 25, 2021, to July 28, 2021. 
 
You asked the Plan to waive the out of network rates for the physician services. You say that the enrollee was 
on vacation and needed medical attention. You also say that this was a medical emergency, and out of network 
should not apply. The Plan denied your request. The Plan says that the enrollee was stabilized and the out of 
network cost sharing applied. The Plan says that the enrollee has been charged the correct cost sharing amount. 
 
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 medical records showing the enrollees condition was 
not, or was no longer, an emergency. Therefore, the Plan cannot cover the service at the out of network rate. 
 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 says that the doctors who give 
you emergency care are the ones who decide when you are stable, and the medical emergency is over. The 
contract also says that enrollees must pay a $200 copayment per day, for days 1-5, for in-network inpatient 
hospital care. The contract also says the in-network rate for physician services while inpatient at a hospital is $0 
copayment. 
 
The Plan says the enrollee must pay 30% coinsurance for the physician services as part of an out of network 
hospital stay. Based on the plan contract, however, the enrollee cannot be asked to pay more than the in-
network rate of $0 copayment the physician services. We decided that the Plan has to waive the out of network 
rates for the physician services (code 99232, 99231, and 99223) provided from July 25, 2021, to July 28, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular testing provided on October 15, 2021. 
 
You asked the Plan to pay for cardiovascular testing. You say that you had a physical in September 2021 to 
renew your commercial driver's license (CDL) and the provider requested that you follow up with cardiology 
because of your history with heart issues before you could obtain a renewed medical card for your CDL. The 
Plan denied your request. The Plan says that physical exams and other services required by third parties such as 
obtaining or maintaining employment or participation in employee programs, required for insurance or 
licensing are not covered under any condition. Medical records support the stress test you received was for 
licensing purposes as required by the Department of Transportation (DOT) for commercial drivers licensing 
renewal. 
 
The Plan contract says that physical exams and other services required by third parties such as obtaining or 
maintaining employment or participation in employee programs, required for insurance or licensing, requested 
sports physicals, or on court order or required for parole or probation are not covered under any condition. 
 We looked at the file and the Plans rules. The file shows that the cardiovascular testing was provided for 
licensing purposes as required by the DOT for commercial drivers licensing renewal. Therefore, we decided 
that the Plan does not have to pay for cardiovascular testing provided on October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyeglasses to be provided by the requested provider. 
 
You asked the Plan to pre-approve eyeglasses to be provided by the requested provider. The Plan denied your 
request. The Plan says low vision services are not a covered benefit. 
 
Medicare generally does not cover routine 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 with $150 single purchase allowance every 2 years through the Plans vision 
provider. 
 
We looked at the file and the Plan's rules. The requested provider is not part of the Plans vision provider. Therefore, we decided that the Plan does not have to pre-approve eyeglasses to be provided by the requested 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eligard. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not 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 pre-approve Eligard.  
 
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a repeat ESI is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have chronic 
low back pain. You underwent a lumbar ESI on November 16, 2021 that provided 50 percent pain relief for 
two days. The records do not document the location of the previous injection, imaging, and plan for the current 
injection. The criteria for coverage are not met and the repeat ESI is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI).