Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a wound care procedure performed 
November 2, 2021. 
 
You asked the Plan to waive the copayment for the wound care. You say that there was no surgery performed, 
only wound cleaning. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing 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 $350 
copayment per visit for surgery or services provided at an outpatient hospital facility.  
 
You have been asked to pay a $350 copayment for the wound care. The wound care falls within the Outpatient 
Surgery, Including Service Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 wound care procedure performed November 
2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for podiatry services provided on January 10, 
2022. 
 
You asked the Plan to waive the deductible for the podiatry services. You say that you should not be 
responsible for paying for the services. The Plan denied your request. The Plan says the correct amount was 
applied to your deductible. 
 
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 $750 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Podiatry Services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the podiatry services were received on January 10, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for podiatry services provided on January 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided during your outpatient 
emergency room visit from January 10, 2022, to January 11, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the self-administered drugs you received 
during your outpatient visit are not covered under your 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 pay for the self-administered drugs 
provided during your outpatient emergency room visit from January 10, 2022, to January 11, 2022.   
Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that this hospital bed is medically 
necessary. The Plan denied your request. The Plan says this type of bed is non-covered under Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a triamcinolone injection performed on 
December 27, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you should not have to pay $2 to 
write a check for $0.20. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for each Part B drug.  
 
You have been asked to pay $0.20, which is 20% of the allowed amount for the injection ($1.02 allowed 
amount x 20% coinsurance = $0.20). The injection falls within the Medicare Part B Prescription Drugs benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for a triamcinolone injection performed on 
December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on December 
9, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an opt-out provider on December 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital services (94060, 94726, 94729, and 95012) 
provided on February 11, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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 did not provide medical records of these services, nor did they submit 
documented attempts to obtain medical records directly from the provider. The Plan says that these services 
were not urgent or emergent in nature. Without medical records we cannot determine whether these services 
were medically necessary or whether it would have been medically reasonable to delay the services until you 
were able to return to the Plans service area. Furthermore, we cannot determine whether a prudent layperson 
would reasonably believe these services were needed on an emergency basis. Therefore, the Plan has not 
shown that its decision to deny payment on the basis that these services were not urgent or emergent in nature 
is medically correct or justified according to Medicare rules and your contract with the Plan. Therefore, we 
decided that the Plan has to pay for the outpatient hospital services (94060, 94726, 94729, and 95012) provided 
on February 11, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the crown (D2740) provided on February 17, 2022. 
 
You asked the Plan to reimburse you for the dental service. You say that you believed the crown would apply 
to your preventive coverage. You also say that being responsible for your copayment would be a financial 
hardship for you. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 and crown is listed as covered, there is 
a 70% coinsurance that applies when you receive this service in network. This is a contractual obligation you 
agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to 
reimburse you for the crown (D2740) provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Bronchodilation (94060), the Plethysmography (94726), and the 
Diffusing capacity (94729) provided on February 11, 2021. 
 
You asked the Plan to pay for codes 94060, 94726, and 94729. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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 did not provide medical records of these services, nor did they submit 
documented attempts to obtain medical records directly from the provider. The Plan says that these services 
were not urgent or emergent in nature. Without medical records we cannot determine whether these services 
were medically necessary or whether it would have been medically reasonable to delay the services until you 
were able to return to the Plans service area. Furthermore, we cannot determine whether a prudent layperson 
would reasonably believe these services were needed on an emergency basis. Therefore, the Plan has not 
shown that its decision to deny payment on the basis that these services were not urgent or emergent in nature 
is medically correct or justified according to Medicare rules and your contract with the Plan. Therefore, we 
decided that the Plan has to pay for the Bronchodilation (94060), the Plethysmography (94726), and the 
Diffusing capacity (94729) provided on February 11, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided November 27, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include the FANCC genes are a 
statutorily excluded service. 
 
We looked at the file and Medicare rules. The panel performed included the FANCC gene. This testing is non-
covered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) provided 
November 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
imaging (D0210), provided by a participating provider on February 7, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation and intraoral imaging. You say that you would 
like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for the rendered 
dental services has already been met and exhausted. 
 
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 one 
comprehensive oral evaluation and intraoral imaging every three years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0210 and D0150 were 
previously provided on September 1, 2021. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and intraoral imaging have not been met. Therefore, we decided 
that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral imaging (D0210), 
provided by a participating provider on February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous Peripheral Nerve Stimulator (Sprint PNS). 
 
You asked the Plan to pre-approve Percutaneous Peripheral Nerve Stimulator (Sprint PNS). You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that PNS is only covered for certain indications. 
 
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 Peripheral Nerve 
Stimulator (Sprint PNS). Our reviewer says that the documentation does not support that the requested services 
are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic right knee pain. The enrollee is status post right total knee replacement. The enrollee has had genicular nerve blocks, physical 
therapy and home exercise. The enrollee takes Oxycodone for pain. The requested PNS is considered an 
experimental/ investigational procedure for knee pain. Therefore, the requested services are not medically 
necessary. 
 
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 Peripheral Nerve Stimulator (Sprint PNS) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Percutaneous Peripheral Nerve Stimulator 
(Sprint PNS).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on February 3, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you do not know why the 
copayment is so high. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing 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 $100 
copayment for each ultrasound.  
 
You have been asked to pay $98.58, which is less than the $100 copayment for the ultrasound. The 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 copayment for a breast ultrasound provided on February 3, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for psychotherapy services provided from 
January 10, 2022, to March 21, 2022. 
 
You asked the Plan to waive the copayments for the psychotherapy services. You say that the counseling 
services should be covered. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing 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 $0 for up 
to 6 sessions per issue. Contact the Plan for more information about obtaining counseling services. 
 
Your contract with the Plan also clearly says that you must pay a $35 copayment for each in-person therapy visit. 
 
The file shows that the Plan was not contacted prior to obtaining the services. Therefore, you have been asked 
to pay a $35 for each visit for the psychotherapy services. The total for the services is $140 ($35 copayment x 4 
visits = $140). The psychotherapy services fall within the Counseling 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 copayments for psychotherapy services provided from January 10, 2022, to March 
21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants on tooth's #18, 19, and 31 (D6010). 
 
You asked the Plan to pre-approve dental implants. You say that the dental implants are medical necessary. The 
Plan denied your request. The Plan says dental implants (D6010) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants on tooth's #18, 19, and 31 (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal by an out-of-network (OON) endodontist. 
 
You asked the Plan to pre-approve OON services. You say that this location is easier to get to when having to 
depend on transportation. The Plan denied your request. The Plan says dental services are not covered when 
seen by an out-of-network provider. 
 
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 record shows you have six in-network endodontists available within a 20 miles radius. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received by an OON provider. Therefore, we decided that the Plan does not have to pre-
approve a root canal by an out-of-network (OON) endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on May 26, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an opt-out provider on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two general dental office visits with an out-of-network 
(OON) provider.
 
You asked the Plan to pre-approve OON dental office visits. You say that the provider was previously in-
network. You also say there are few dentists in your area and the next in-network dentist is over 30 miles away. 
The Plan denied your request. The Plan says dental services are not covered when seen by an OON provider. 
 
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 record shows there is an in-network dentist in your area. Though the Plan offers a dental benefit in excess 
of Medicare coverage, the requested items or services are not covered under this benefit when received by an 
OON provider. Therefore, we decided that the Plan does not have to pre-approve two general dental office 
visits with an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for drug testing performed on April 29, 2021, 
and September 16, 2021. 
 
You asked the Plan to waive the copayments for the drug testing. You say that you were under the impression 
that there would be no copayments under this plan. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 $20 
copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film X-rays, and ultrasounds.  
 
You have been asked to pay a $20 copayment per visit for the drug testing. The total for both visits is $40. The 
drug testing 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 drug testing performed on April 29, 2021, and 
September 16, 2021.