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

 
We decided that the Plan does not have to pay for the laboratory services coded 0315U for date of service 
January 18, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that only certain MolDX tests are covered. 
 
We looked at the file and Medicare rules. The SCC test provided is not covered. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded 0315U for date of service January 18, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the requested Evenity is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Forteo first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has age related osteoporosis without osteoporotic fracture. The requested medication is a new start. 
The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one 
alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse 
effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The 
requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eye exam (92004) provided on April 21, 2023. 
 You asked the Plan to pay for the vision care. You say that your previous evaluation was completely wrong. 
You say that you were given the same prescription for both eye despite having scarring on your left eye. You 
also say that this was urgent because you need a new prescription to pass with the Department of Motor 
Vehicles (DMV). The Plan denied your request. The Plan says the benefit for a routine eye exam 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 one routine eye exam per year. 
 
We looked at the file and the Plan's rules. A routine eye exam is covered once per year. Based on this 
information, we decided that the Plan's rules for coverage of the vision care have not been met. The record 
shows that the Plan paid for a routine eye exam within the last year. Therefore, we decided that the Plan does 
not have to pay for the routine eye exam (92004) provided on April 21, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 28, 2023. 
 
You asked the Plan to pay for ambulance services. You say that this service is supported in the records. 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 ambulance services 
provided on February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic casts (D0470), extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated 
(D7210), and bone replacement graft for ridge preservation - per site (D7953) provided on December 28, 2022. 
 You asked the Plan to pay for the dental services represented by codes D0470, D7210 and D7953. You say that 
you should be able to use all of your annual amount. The Plan denied your request. The Plan says the requested 
procedures, D0470 and D7953 do not appear on the chart and are therefore not covered. The Plan also says 
D7210 was received from an out-of-network provided and is not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the procedures D0470 and D7953 are 
not among those covered under this benefit. The extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth is not covered under this benefit when received from an out-of-network provider Therefore, 
we decided that the Plan does not have to pay for diagnostic casts (D0470), extraction, erupted tooth requiring 
removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated 
(D7210), and bone replacement graft for ridge preservation - per site (D7953) provided on December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee requires ventilatory support during sleep as treatment for severe COPD due to 
sarcoidosis. However, it appears that the enrollee's needs would be met with BiPAP with average volume-
assured pressure support (AVAPS) and a backup rate. There is no evidence that this has been tried and shown 
to fail. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued use of a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided 
on January 17, 2023, to March 7, 2023. 
 
You asked the Plan to pay for limited oral evaluation. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 pay for limited 
oral evaluation - problem focused (D0140) provided on January 17, 2023, to March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutments (D6057), and abutment 
supported crowns (D6058). 
 
You asked the Plan to pay for dental implants. You say that you need this dental work. The Plan denied your 
request. The Plan says dental implants are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for custom 
fabricated abutments (D6057), and abutment supported crowns (D6058).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each ambulance service provided on 
March 30, 2022, to April 07, 2022. 
 
You asked the Plan to reduce the copayment for each ambulance service. You say that the mileage was charged 
incorrectly. 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 $265 
copayment for in-network ambulance services. 
 
You have been asked to pay a $265 copayment for each ambulance service. This item/service falls within the 
in-network 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. However, since the allowed amount is less than the standard copayment, you 
only owe $263.22 for March 30, 2022, and $257.61 for April 7, 2022. Therefore, we decided that the Plan does 
not have to reduce the copayment for each ambulance service provided on March 30, 2022, to April 07, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
December 22, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not be 
charged as you did not call the ambulance. 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 ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance transportation. This item/service 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 the 
ambulance transportation provided on December 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the replacement cochlear implant devices 
provided on December 08, 2022. 
 
You asked the Plan to waive the coinsurance for the replacement cochlear implant devices. You say that you 
were told by the provider you did not owe a payment. 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 in-network durable medical equipment. 
 
You have been asked to pay 20% coinsurance for the replacement cochlear implant devices. This item/service 
falls within the in-network durable medical equipment 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 coinsurance for the replacement cochlear implant devices provided on December 08, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
May 17, 2022. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you were unaware 
that you would 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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for the emergency room services. 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 
services provided on May 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 10, 2023, to 
January 11, 2023. 
 
You asked the Plan to pay for the medication. You say that you shouldn't be charged for this. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
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 self-administered drugs provided 
on January 10, 2023, to January 11, 2023.  
 
Benefits for the medication 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 waive the coinsurance for each drug injection provided on February 
06, 2023, to February 16, 2023. 
 
You asked the Plan to waive the coinsurance for each drug injection. You say that theses costs should be 
covered by the Plan. 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 Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for each drug injection. This item/service falls within the 
Medicare Part B drugs 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 coinsurance for each drug 
injection provided on February 06, 2023, to February 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 29, 2022. 
 
You asked the Plan to pay for lab services. You say that this is supported in the records. 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 lab services provided on 
November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 21, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services should be covered. 
The Plan denied your request. The Plan says this was not authorized. 
 
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 subsequent nursing facility care provided on 
November 21, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
February 26, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that this was an emergency 
and could not decide where you would go. 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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for the emergency room visit. 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 visit 
provided on February 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on 
January 04, 2023. 
 
You asked the Plan to waive the copayment for the electrocardiogram (EKG). You say that you were told this 
would be fully covered after your $50 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 $50 
copayment for in-network outpatient diagnostic tests, including EKGs. 
 
You have been asked to pay a $50 copayment for the electrocardiogram (EKG). This item/service falls within 
the in-network outpatient diagnostic tests, including EKGs 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. However, since the allowed amount is less than the 
standard copayment, you only owe $15.81. Therefore, we decided that the Plan does not have to waive the 
copayment for the electrocardiogram (EKG) provided on January 04, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services, and travel allowance provided on March 02, 
2023. 
 
You asked the Plan to pay for lab services, and travel allowance. You say that this is supported in the records. 
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 lab services, and travel 
allowance provided on March 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 23, 2023. 
 
You asked the Plan to pay for lab services. You say that these services provide valuable information for 
providers to use in determining the appropriate treatment. 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 lab services provided on 
January 23, 2023.