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

 
We decided that the Plan does not have to pre-approve the prefabricated post and core (D2954) for tooth #'s 13 
and 15. 
 
You asked the Plan to pre-approve the prefabricated post and core (D2954) for tooth #'s 13 and 15. You say 
that the bridge fell off after three weeks and again after six months. You say that the new dentist is going to fix 
it the correct way. The Plan denied your request. The Plan says cores and crowns are only covered once in a 
five-year period per tooth.  
 
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 
one core per tooth every five years. The Plan paid for core buildup's provided on April 23, 2019, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the prefabricated post 
and core (D2954) for tooth #'s 13 and 15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve the fixed partial denture sectioning (D9120). You say that you need a bridge 
cut to remove a tooth that is abscessed. You say that you took at least 3 to 4 rounds of antibiotics to try to treat 
the infection and get rid of the swelling. The Plan denied your request. The Plan says the fixed partial denture 
sectioning 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 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 the 
fixed partial denture sectioning (D9120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care office visit (99211) 
provided. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $65 
copayment for Medicare-covered urgently needed care services.  
 
You have been asked to pay a $65 copayment for the urgent care services provided. 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 urgent care office visit (99211) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotic devices (E0673, E0650, 97760, E0666) provided 
January 9, 2020 to January 30, 2020. 
 
You asked the Plan to pay for the orthotic devices. You say that the items were medically necessary. The Plan 
denied your request. The Plan says rules for a telehealth consult were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for orthotic devices (E0673, 
E0650, 97760, E0666) provided January 9, 2020 to January 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for physical therapy provided by an in-
network provider on December 31, 2018. 
 
You asked the Plan to waive the coinsurance for physical therapy. You say that you do not agree with this 
coinsurance. 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 20% 
coinsurance for outpatient rehabilitation services/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for physical therapy. The total allowed 
amount is $118.31. The total amount you are being asked to pay is $23.67. The correct coinsurance has bene 
applied to the services that were provided. Physical therapy falls within the outpatient rehabilitation services/in-
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 physical therapy provided 
by an in-network provider on December 31, 2018.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 pane rendered on November 19, 2019. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 pane rendered on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #4. 
 
You asked the Plan to pre-approve the crown. You say that a crown restoration is the most adequate treatment 
for longevity in protecting this tooth. The Plan denied your request. The Plan says the crown for tooth #4 is not 
medically necessary. 
 
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 covers the crown 
when the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
service does not meet coverage criteria. Our physician reviewer found there does not appear from the provided 
x-rays to be significant structural breakdown or cuspal involvement such that a conventional restoration would 
not be appropriate. Our reviewer also found that tooth #4 does not appear to have three or more surfaces and a 
cusp involved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for tooth #4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen contents, gas, 1 month's supply (E0443) 
provoded. 
 
You asked the Plan to pay for portable oxygen contents. You say that the 36 month has been billed and paid 
therefore the E1390 E0431 is considered capped and the provider can bill for E0443 per month as long as the 
patient has O2 up until the 60 month rental. The Plan denied your request. The Plan says oxygen content is 
included in the equipment rental. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
In this case a review of the file confirms that it was the 31st month of 
billing for the rental of equipment coded E1390 and 29th month of billing for the rental of equipment coded 
E0431. Therefore, the benefit limit has not been met. Based on this information, we decided that Medicare 
rules for coverage of portable oxygen contents have not been met. Therefore, we decided that the Plan does not 
have to pay for the portable oxygen contents, gas, 1 month's supply (E0443).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided by a non-
participating provider on January 14, 2020 to March 6, 2020. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you have been seeing this 
provider for over 15 years. The Plan denied your request. The Plan says the correct copayments have 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 $65 
copayment for podiatry services/out-of-network.  
 
You have been asked to pay a $65 copayment for each podiatry office visit. The total amount you are being 
asked to pay is $195 ($65 x 3 visits = $195). Podiatry services fall within the podiatry services/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 copayment for podiatry services provided by a 
non-participating provider on January 14, 2020 to March 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on January 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the service are 
available in-network. 
 
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 the enrollee by an out-of-network provider 
on January 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0427) provided. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $395 
copayment per one-way trip via ground ambulance.  
 
You have been asked to pay a $395 copayment for the one-way ground ambulance trip provided. 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 service (A0427) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Medicare-covered eye exam provided by 
on November 7, 2019. 
 
You asked the Plan to waive the copayment for the Medicare-covered eye exam. You say that this exam is for a 
yearly screening due to being a diabetic. You say your Plan covers this exam once per year, yet you were 
charged a $20 copayment. The Plan denied your request. The Plan says there is a $20 copayment for a 
Medicare-covered eye exam. 
 
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 
copayment for vision care for a Medicare-covered eye exam. 
 
You have been asked to pay $20 copayment for the Medicare-covered eye exam. The Medicare-covered 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 a 
Medicare-covered eye exam provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist visit and an ophthalmic 
ultrasound provided on July 10, 2020. 
 
You asked the Plan to waive the copayments for a specialist visit and an ophthalmic ultrasound. You say that 
you disagree with the $100 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 $35 
copayment for each specialist visit. Your contract with the Plan also clearly says that you must pay a $40 
copayment for each basic imaging service. 
 
The medical records show that you had a specialist visit on July 10, 2020. Therefore, you are responsible to pay 
the $35 copayment.   
 
The medical records show that you received an ophthalmic ultrasound on July 10, 2020. Therefore, you are 
responsible to pay the $40 copayment.  
 
The total amount you owe is: $75.  
 
You have been asked to pay the total copayment amount of $75 for a specialist visit and an ophthalmic 
ultrasound. A specialist visit falls within the physician/practitioner services, including doctor's office visits 
benefit category. An ophthalmic ultrasound 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 copayments for a specialist visit and an 
ophthalmic ultrasound provided on July 10, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth consult (G0426) provided on March 27, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the telehealth consult. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network 
providers available. 
 
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 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 a telehealth consult (G0426) provided on March 27, 2020 by an out of network 
(OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional unit of codes A0425 and A0429 provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
duplicate charges. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT codes A0425 and A0429 are not supported in the medical record. The medical 
record only supports 1 unit of CPT codes A0425 and A0429. 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 the additional unit of codes A0425 and A0429.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis Emu 
 
You asked the Plan to pre-approve Restasis Emu. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Restasis Emu is not covered under the enrollee's Medicare 
Part B benefit. 
 
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 Restasis Emu  
 
Benefits for Restasis Emu 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure provided on May 8, 
2020. 
 
You asked the Plan to pay for the unspecified preventive procedure. You say that you are allowed 2 cleanings 
and prophylaxis procedures each year. You say that you should be given that cost for this procedure. The Plan 
denied your request. The Plan says 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. 
 
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 
unspecified preventive procedure provided on May 8, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 physician's services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist hand finger orthosis, without joint(s) provided on 
April 28, 2020. 
 
You asked the Plan to pay for the wrist hand finger orthosis, without joint(s). The Plan denied your request. 
The Plan says the Plan requires utilization of network providers when possible and available, and requires 
authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or 
emergency situation, has been documented 
 
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 a wrist hand finger orthosis, without joint(s) provided on April 
28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vascular surgery services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the vascular surgery services. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent 
nor urgent to seek out-of-network care. The Plan says that there are in-network Vascular surgeons available to 
the enrollee that can provide the care and treatment being requested. 
 
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 vascular surgery services to be provided by an out of network (OON) provider.