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

 
We decided that the Plan does not have to waive the coinsurance for echocardiography provided. 
 
You asked the Plan to waive the coinsurance for echocardiography. You say that you have not been charged in 
the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 20% 
coinsurance for diagnostic procedures and tests. 
 
You received echocardiography. The allowed amount is $84.67 and 20% of that is $16.93.   
 
You have been asked to pay the total coinsurance amount of $16.93 for echocardiography. Echocardiography 
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 coinsurance for echocardiography provided.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Minimally Invasive Spinal Fusion (27279). 
 
You asked the Plan to pre-approve the Minimally Invasive Spinal Fusion. You say that the service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that this procedure is only covered when 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 the Minimally Invasive Spinal Fusion. 
Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the 
record shows the enrollee had only limited medication optimization, no bracing and has not had a trial of at 
least one therapeutic intra-articular SIJ injection (i.e. corticosteroid injection). There is no imaging of the SI 
joint submitted. 
 
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 Minimally Invasive Spinal Fusion have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Minimally Invasive Spinal Fusion (27279).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid services (V5261, V5160) provided on 
February 27, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid services. You say that you were unaware you were receiving 
services from an OON provider. The Plan denied your request. The Plan says there is no coverage for hearing 
aids if received from an OON provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through the Plan's hearing aid vendor.  
 
We looked at the file and the Plan's rules. The file indicates that the hearing aids were purchased from an OON 
provider and not the Plan's hearing aid vendor. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hearing aid services (V5261, V5160) provided on February 27, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve thromboendarterectomy. You say that you are appealing based on medical 
necessity. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this provider is out-of-network with the Plan and the enrollee can receive this service from an in-
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 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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 10, 2020, by an 
OON provider. 
 
You asked the Plan to pay for a medical eye exam. You say that this is an approved treatment under your 
insurance. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 medical services provided on March 10, 2020, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 10, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the front desk secretary failed to get 
authorization, but these services were performed in good faith. The Plan denied your request. The Plan says 
unauthorized, non-plan 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 in this case is not a network provider with the Plan. 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 medical services provided on June 10, 2020 by an out of 
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on May 19, 2020. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you have never been charged in 
the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 $50 
copayment for laboratory services provided at an outpatient hospital facility.  
 
The record show that you received laboratory tests on May 19, 2020, at an outpatient hospital facility. 
Therefore, you are responsible to pay the $50 copayment.  
 
You have been asked to pay a $50 copayment for laboratory tests. Laboratory tests 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 laboratory tests provided on May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for extra-oral posterior dental radiographic image (D0251) provided on 
August 11, 2020. 
 
You asked the Plan to pay for extra-oral posterior dental radiographic image (X-Ray). You say that the service 
was medically necessary. The Plan denied your request. The Plan says that the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers extra -oral 
posterior dental radiographic image (x-Ray). 
  
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of extra-oral posterior dental radiographic image (x-Ray) have been met. Specifically, the service is a 
covered benefit. Therefore, we decided that the Plan has to pay for extra-oral posterior dental radiographic 
image (D0251) provided on August 11, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental 
gradient pressure pneumatic appliance (E0673 LT, RT) provided on March 18, 2020. 
 
 
You asked the Plan to pay for the compression device and appliance. You say that you would like to request be 
reconsidered for payment. You feel that you should be compensated for services provided to the enrollee for 
their safety and well-being. The Plan denied your request. The Plan says the requested services are not 
medically appropriate and non-covered per Medicare. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 compression device and appliance. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided there is no documentation that the 
enrollee's clinical circumstances meet the requirements listed in the National Coverage Determination for 
Medicare coverage. The devices were ordered for prevention of a deep vein thrombosis after arthroscopic knee 
surgery. There was no documentation of arterial disease to support the use of E0675 and thus no documentation 
to support use of E0673 RT, LT. 
 
 
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 compression device and appliance have not been met. Therefore, we decided 
that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental gradient 
pressure pneumatic appliance (E0673 LT, RT) provided on March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for a coronal structure buildup (D2950) 
and a resin-based composite (D2331) received on June 9, 2020. 
You asked the Plan to provide additional payment for a coronal structure buildup and a resin-based composite. 
You say that the Plan paid twice for a prior date of service and you want the overpayment to be refunded and 
applied to a later outstanding claim. The Plan recouped the overpayment and credited it to the amount you are 
being charged but partially denied your request. The Plan says rules for additional payment have not been met. 
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. The Plan benefit includes a 
$1,500 combined allowance for supplemental preventive and comprehensive services every year.  
We looked at the case file and Medicare rules. We noted that the Plan recouped its overpayment for a prior date 
of service and credited $132 to the amount you are being charged for June 9, 2020. This credit exhausts your 
annual $1,500 combined allowance for supplemental preventive and comprehensive services. Based on this 
information, we decided that the Plan's rules for additional payment for a coronal structure buildup and a resin-
based composite have not been met. Therefore, we decided that the Plan does not have to provide additional 
payment for a coronal structure buildup (D2950) and a resin-based composite (D2331) received on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prostate predictive testing (81551) provided on June 16, 2020 
by the appealing provider. 
 
You asked the Plan to pre-approve the prostate predictive testing. You say that the services were provided and payment 
should be rendered. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed 
above, are not covered. 
 
The test at issue in this appeal, prostate predictive testing, is being requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve 
the prostate predictive testing (81551) provided on June 16, 2020 by the appealing provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a weight scale. 
 
You asked the Plan to pre-approve these services. You say that you would like to monitor your weight loss. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a weight scale.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional extraction (D7140) provided on March 13, 
2020. 
 
You asked the Plan to pay for the dental service. You say that the extraction was medically necessary. The Plan 
denied your request. The Plan says 6 extractions per calendar year are covered. The Plan says that the 
frequency limit has been exceeded. 
 
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 frequency limit for extractions has 
been exceeded. The record shows that the Plan paid for 6 extractions that you received on the date of service, 
thus exhausting the benefit. Therefore, we decided that the Plan does not have to pay for the additional 
extraction (D7140) provided on March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts (D0470), the complete upper denture 
(D5110), and the filling (D2332) provided from June 24, 2020, to July 13, 2020. 
 
You asked the Plan to pay for the dental services. You say that you heard that Medicare would be allowing 
more benefits in the new year. You say that based on this, you decided to get dentures. You also say that you 
are on a limited income and are disappointed that you did not receive any help the services you received.  The 
Plan denied your request. The Plan says diagnostic casts is not listed as a covered service. The Plan says that 
dentures are not listed as a covered service. The Plan also says that fillings are not listed as a 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
diagnostic casts (D0470), the complete upper denture (D5110), and the filling (D2332) provided from June 24, 
2020, to July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the ophthalmology services provided on February 
11, 2020. 
 
You asked the Plan to reimburse you the ophthalmology services. You say that the Plan should reimburse you 
the total charge. The Plan denied your request. The Plan says the provider did not bill the service medically. 
 
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 find that the provider did not bill correctly. The provider billed the claim with routine eye exam codes and 
you received the correct benefit reimbursement. Based on this information, we decided that Medicare rules for 
coverage of the ophthalmology medical examination have not been met. Therefore, we decided that the Plan 
does not have to reimburse you for the ophthalmology services provided on February 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 6, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were provided in good faith and 
the claim should be paid. The Plan denied your request. The Plan says unauthorized, non-plan 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 in this case is not a network provider with the Plan. 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 the medical services provided on August 6, 2020 by an out of network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bathtub. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the chest for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says only the CT of the abdomen/pelvis can be approved. 
 
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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found per the NCCN 
guidelines on rectal cancer, routine imaging is not indicated for stage I rectal cancer. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan of the chest for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve conscious sedation for dental services (D9239). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says these are not covered services. 
 
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 pre-approve 
conscious sedation for dental services (D9239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the electrical stimulator. You say that you require this device. The Plan 
denied your request. The Plan says the associated network exception for out of network (OON) services does 
not meet the requirements for approval. The request is not approved. 
 
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 
the medical services to be provided by an out of network (OON) provider.