Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 3 additional extractions provided on April 22, 2020. 
 
You asked the Plan to pay for 3 additional extractions. You say that this is a grievance for you to pay the rest of 
the bill. You say that you need help. The Plan denied your request. The Plan says your plan only covers two 
dental extractions per calendar year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
two extractions per calendar year. The Plan paid for two extractions provided on April 22, 2020, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for 3 additional extractions 
provided on April 22, 2020.
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 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. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple 
therapies such as physical and occupational therapy but the documentation does not support that your 
functional status requires an 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on May 5, 2020. 
 
You asked the Plan to pay for the periapical x-ray. You say that you were in pain. You say that you were told 
you needed an x-ray. You say that you cannot afford to pay for services that are not approved and covered by 
your plan. The Plan denied your request. The Plan says periapical x-ray is not listed as 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 Plan's 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 the 
periapical x-ray (D0220) provided on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug tests utilizing one drug identification 
method (G0480) provided on June 10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for drug tests. You say that medically necessary services were provided in good 
faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network providers. 
 
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 has network providers 
available who can provide 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 the definitive drug tests utilizing one drug 
identification method (G0480) provided on June 10, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 6. 
 
You asked the Plan to pre-approve the dental service. You say that tooth # 6 has an existing crown with decay 
present. You say that the standard of care is replacing a failing fixed prosthesis with another fixed prosthesis. 
The Plan denied your request. The Plan says the root canal is not listed as a covered service. The Plan also says 
any services not listed are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested root canal for tooth # 6 is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
root canal (D3310) for tooth # 6.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network telehealth services provided to the enrollee 
from May 28, 2020, to June 1, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be paid by the Plan. The Plan 
denied your request. The Plan says the enrollee did not have prior authorization for care from an out of 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 provider in this case is not a network provider with the Plan. 
The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not 
pre-approve the service 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 out of network telehealth services provided to the 
enrollee from May 28, 2020, to June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit (99204) on April 9, 
2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you don't believe you 
should have a copayment because this service was rendered as a follow-up to surgery. The Plan denied your 
request. The Plan says the correct copayment 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). Your contract with the Plan clearly says that you must pay a $45 
copayment for each covered visit or consultation in an outpatient location with a specialist. The contract also 
says that you pay $0 for a follow up visit following a discharge from a hospital, skilled nursing facility, 
Community Mental Health Centers stay, outpatient observation, or partial hospitalization that meets the 
requirements as defined by Medicare. 
 
You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls within 
the "Physician/Practitioner services, including doctor's office visits" benefit category. The case record indicates 
that you had a telehealth visit on April 4, 2020, as a follow up to your surgery. This means that you have been 
asked to pay the correct amount for the office visit on April 9, 2020, 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 (99204) on April 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for visiting nurse services provided to the enrollee on August 22, 
2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do not support the services billed. The Plan says that the appeal 
states medical evaluation was completed by a particular nurse practitioner, however there is no documentation 
in the submitted medical records to support this statement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and the records provided must support the 
services billed. In this case, there were insufficient records provided to show these services were billed 
appropriately. Therefore, we decided that the Plan does not have to pay for visiting nurse services provided to 
the enrollee on August 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0480 provided on December 6, 
2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 G0480 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug 
class(es), including metabolite(s) if performed. 
 
We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation 
submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to 
be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0480 
provided on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on July 13, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you do not agree with this 
copayment. The Plan denied your request. The Plan says the correct copayment has been 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). Your contract with the Plan clearly says that you must pay a $40 
copayment for physician/practitioner services/network/specialist.  
 
You have been asked to pay a $40 copayment for specialist services. Specialist services fall within the 
physician/practitioner services/network/specialist 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 specialist services provided by a participating provider on July 13, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 15, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you believe this should be covered 
under non-radiological diagnostic services. The Plan denied your request. The Plan says the copayment you are 
being charged 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 $100 
copayment for each in-network Medicare-covered radiological diagnostic service, not including X-rays, 
performed in a physicians office or at a free-standing facility.  
 
You have been asked to pay a $100 copayment for an ultrasound. Ultrasounds fall 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 an ultrasound provided on May 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by an out-
of-network provider on February 24, 2020. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you would like this 
reprocessed as an in-network provider. The Plan denied your request. The Plan says the correct coinsurance has 
been 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). Your contract with the Plan clearly says that you must pay a 30% 
coinsurance for outpatient surgery/out-of-network.  
 
You have been asked to pay a 30% coinsurance of the allowed amount for an outpatient surgery. The total 
allowed amount $5,748.65. The total amount you are being asked to pay is $1,724.60 ($5,748.65 x 30% = 
$1,724.60). An outpatient surgery falls within the outpatient surgery/out-of-network 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 an outpatient surgery provided by an out-of-network 
provider on February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker purchased on April 6, 2020. 
 
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 the provider is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
The file shows that the services were purchased from a provider that is not Medicare-certified. Therefore, we 
decided that the Plan does not have to pay for the walker purchased on April 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram services provided on March 22, 2020. 
 
You asked the Plan to pay for the services provided. You say that the services meet the conditions for separate 
payment. The Plan denied your request. The Plan says the interpretation of telemetric rhythm strips is part of 
the evaluation and management services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The services at issue are not separately payable. Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the electrocardiogram services provided on March 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the cardiac rehabilitation services rendered 
from December 4, 2019 to December 30, 2019. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the copayments were applied 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 $25 
copayment for each Medicare-covered cardiac rehabilitation visit.  
 
Review of the file shows that you received cardiac rehabilitation for nine dates of service from December 4, 
2019 to December 30, 2019. You have been asked to pay a $25 copayment per date of service for these 
services, for a total of $225. These services fall within the Medicare-covered cardiac rehabilitation visit 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 copayments for the cardiac rehabilitation services rendered 
from December 4, 2019 to December 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan has to pre-approve a CT scan of the abdomen/pelvis. 
 
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says that a CT scan is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan. Our reviewer says that the 
requested CT scan is not medically reasonable and necessary. Our physician reviewer found that given the 
undiagnosed etiology of condition and the utility of information gained from the scan to assist in the diagnosis.  
The CT scan is indicated. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan of the abdomen/pelvis.  
 
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: ER
Decision: Favorable

 
We decided that the Plan has to pay for the mental health emergency crisis management services provided on 
February 28, 2020. 
 
You asked the Plan to pay for the mental health crisis management services. You say that these services were 
necessary to determine whether the enrollee was in immediate danger of self-harm or harm to others. The Plan 
denied your request. The Plan says that a corrected claim needs to be submitted with a treatment authorization 
code. 
 
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 has not provided a valid denial rationale in this case. It is stated that 
this claim was not correctly billed due to a missing treatment authorization code. No citation from any 
regulation was provided showing that this type of service requires any such code. This service was provided in 
an emergency situation in which there was thought to be a risk of self-harm. Without a valid rationale, we find 
that this denial of payment is not supported. Therefore, we decided that the Plan has to pay for the mental 
health emergency crisis management services provided on February 28, 2020.  
 
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-approveBreo Ellipta for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary.The Plandenied 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-approveBreo Ellipta for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on June 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on June 
16, 2020.