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

We decided that the Plan does not have to pay for the retainer crowns (D6740 x 2) and the pontic (D6245) 
provided on June 15, 2020. 
 
You asked the Plan to pay for the dental services. You say that you had a molar break. You say that you had a 
gap and an exposed root. You say that you could not chew on both sides of your mouth without opposing 
molars. You also say that you have no choice but to get a bridge as you have lost 12 pounds since. The Plan 
denied your request. The Plan says retainer crowns are not listed as a covered service. The Plan says pontic is 
not listed as a covered service either. 
 
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 
retainer crowns (D6740 x 2) and the pontic (D6245) provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 21, 2020.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 servicesat 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 on May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a non-participating provider on May 4, 2020.You asked the Plan to waive the copayment for wound care. You say that you were unaware the facility was out-of-network. 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 $325 copayment for outpatient surgery/in-network. You have been asked to pay a $325 copayment for wound care. The in-network copayment for these services is $325; therefore, the correct copayment has been applied. Wound care falls within the outpatient surgery/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 copayment for an outpatient surgery provided by a non-participating provider on May 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transport (A0425, A0427) 
provided March 18, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be 
waived. 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 $270 
copayment for ambulance services.  
 
You have been asked to pay a $270 copayment for the ambulance transport. The ambulance transport 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 an 
ambulance transport (A0425, A0427) provided March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the partial denture. You say that you have 4 teeth on the bottom. You say 
that your partial was destroyed in a car accident. You say that you are unable to eat properly. You also say that 
it is affecting your confidence. The Plan denied your request. The Plan says 1 denture is covered every 5 plan 
years. The Plan also says the frequency limit has been reached. 
 
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 of 1 denture every 
5 plan years has been reached. The record shows that the plan paid for a partial denture that you received on 
August 27, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture 
(D5214).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery you had at an 
ambulatory surgical center on May 28, 2020. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that this surgery was necessary 
to remove scar tissue.  You also said that you believe this surgery took place in a doctor's office and only took 
15-20 seconds. The Plan denied your request. The Plan says you were charged this copayment 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 $325 
copayment for outpatient surgery in an outpatient hospital or ambulatory surgical center setting.  
 
You have been asked to pay a $325 copayment for the outpatient surgery. The billing records show that these 
services were provided in an ambulatory surgical center setting. 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 outpatient surgery you had at an ambulatory surgical center on May 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on May 20, 2020 to 
May 27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the inpatient services. You say that you are submitting this letter for 
reconsideration as noted due to medical necessity for the admission. You request reconsideration for 
circumstances regarding no notification for his inpatient admission. The Plan denied your request. The Plan 
says enrollee's must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 inpatient hospital services provided on May 
20, 2020 to May 27, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the gynecology visit you had on July 17, 
2020. 
 
You asked the Plan to waive the copayment for the gynecology visit. You say that since you only saw a 
physician's assistant, you shouldn't have to pay the specialist copayment. The Plan denied your request. The 
Plan says you were charged this copayment correctly.  The Plan says that any non-Primary Care Provider visit 
is charged at the specialist copayment rate. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for specialist physician and practitioner visits.  
 
You have been asked to pay a $30 copayment for the gynecology visit. Your Evidence of Coverage says that 
visits with a physician OR a practitioner (such as a physician?s assistant) fall under the physician office visit 
cost sharing.  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 gynecology visit you had on July 17, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (63650). 
 
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array, epidural. You 
say that this service is necessary due to the enrollee's medical condition. The Plan denied your request. The 
Plan says the enrollee does not meet Medicare criteria for coverage of this service. 
 
The Plan follows Medicare rules. Medicare rules say that the implantation of the stimulator is used only as a 
late resort (if not a last resort) for patients with chronic intractable pain. 
 
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 percutaneous implantation of 
neurostimulator electrode array, epidural. Our reviewer says that percutaneous implantation of neurostimulator 
electrode array, epidural is not medically necessary at this time. Our physician reviewer found there was no 
indication in the records provided that the member had ever undergone surgery for their neck pain. Nor was 
there any indication that there was not an (anatomical) indication for which surgery would not be appropriate. 
Given that there is a potential surgical option available to the member, the proposed service cannot be said to 
be a treatment of "last resort". Consequently, the requirements for Medicare coverage are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array, epidural have not 
been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of 
neurostimulator electrode array, epidural (63650).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a vision aid and sales tax (S9999, V2600) provided May 28, 
2020. 
 
You asked the Plan to pay for the vision aid. You say that the device is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for a vision aid and sales tax (S9999, V2600) provided May 28, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for chiropractic services provided by a 
participating provider on May 27, 2020. 
 
You asked the Plan to waive the deductible for chiropractic services. You say that you do not agree with this 
deductible. The Plan denied your request. The Plan says the correct deductible amount has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible for chiropractic services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category chiropractic 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible for chiropractic services. This cost sharing is a contractual obligation that had not been met at the 
time chiropractic services was received on May 27, 2020. The total amount you are being asked to pay is 
$28.13. Therefore, we decided that the Plan does not have to waive the deductible for chiropractic services 
provided by a participating provider on May 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care (99291) provided from December 5, 2019, to 
December 9, 2019. 
 
You asked the Plan to pay for critical care. You say that this code is shown in the records. The Plan denied 
your request. The Plan says the time spent on critical care is not documented. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent on critical 
care is not documented. Based on this information, we decided that Medicare rules for coverage of critical care 
have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided 
from December 5, 2019, to December 9, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided by out-of-network provider on 
February 21, 2020. 
 
You asked the Plan to pay for physical therapy. You say that the medical records should be reviewed for 
reconsideration of payment. The Plan denied your request. The Plan says the out-of-network 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 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 physical therapy provided by out-of-network 
provider on February 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe computed tomography (CT) scan you had on June 12, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that you don'tunderstand why your plan didn't pay anything towards this medically necessary test.The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for the CT scan ($112.91) is less than your copayment obligation, you are responsible for the full 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 $180 copayment for advanced imaging services. You have been asked to pay up to a $180 copayment for the CT scan. The CT scan falls within the advanced imaging 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 forthe computed tomography (CT) scan you had on June 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by on June 17, 2020. 
 
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says out-of-network 
services are 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 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 physical therapy provided by on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forpodiatry services provided on February 26, 2020 by an out of network (OON) provider.You asked the Plan to pay forpodiatry services. You say that you would like this claim reprocessed and approvedfor payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.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 forpodiatry services provided on February 26, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon June 22, 2020.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 physician's services.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 on June 22, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room (ER) services you had on January 17, 2020.You asked the Plan to waive the copayment forthe ER services. You say that you shouldn't have to pay this copayment because you were not treated well and you believe that the proper tests were not done.The Plan denied your request. The Plan says you were charged this copayment 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 $90 copayment for emergency room visits. You have been asked to pay a $90 copayment for the ER services. This copayment applies regardless of whether you were satisfied with the service you received. 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 forthe emergency room (ER) services you had on January 17, 2020.Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
provider on May 11, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that there should not be a copayment for this. 
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 $10 
copayment for outpatient diagnostic tests/basic radiology services/specialist office.  
 
You have been asked to pay a $10 copayment for an x-ray. An x-ray falls within the outpatient diagnostic 
tests/basic radiology services/specialist office 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 x-ray provided by a participating provider on May 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crowns. 
 
You asked the Plan to pre-approve the crowns. 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 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 the preventive or diagnostic benefit. Therefore, we decided that the Plan does not 
have to pre-approve the crowns.