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

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001) for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is not enough evidence that this type of radiation therapy 
guidance is needed or effective for your skin cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Using ultrasound on 
a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for daily simple simulations (this 
does not seem to be requested or disputed here) and/or Image-guided radiation therapy (IGRT) for a technology 
for which need has not been established by published data or supported by consensus guidelines (many of 
which recommend against treatment with these devices in general- citations below) is not necessary. Billing for 
daily IGRT would not be furnished in accordance with accepted standards of medical practice. Our physician 
reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve ultrasound guided radiation therapy (G6001) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on February 25, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing the enrollee is being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $25 copayment for provider and professional services at specialists office. Covered services 
include consultation, diagnosis, and treatment by a specialist. 
 
The enrollee has been asked to pay a $25 copayment for office visit. Office visits fall within the 
Physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for office visit on February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 15, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee meets medical criteria for this 
service. The Plan denied your request. The Plan says the ordering physician and provider are out-of-network, 
and the services were not approved in advance. 
  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 had network providers 
available who could have provided 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 genetic testing provided on December 15, 
2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on June 14, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs. These drugs are covered under Part B of Original 
Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs include 
drugs that usually arent self-administered by the patient and are injected or infused while you are getting 
physician, hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of 
$5,169.60 and the allowed amount is $2,556. $2,556 x 20% = $511.20. Therefore, results in the total cost 
sharing amount of $511.20. 
 
 
 
 You have been asked to pay a 20% coinsurance for Part B drugs. Part B drugs fall 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 Part B drugs on 
June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought this would be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 21, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided on May 12, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you needed new dentures. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 12, 2019. 
Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided on 
May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999) and 
radiographic/surgical implant index (D6190) provided by an out-of-network provider on May 2, 2022. 
 
You asked the Plan to pay for an unspecified adjunctive procedure and radiographic/surgical implant index. 
You say that you believe the Plan should pay for this. The Plan denied your request. The Plan says the 
enrollee's maximum dental allowance 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 Plans coverage rules apply in this case. 
 
We looked at the file and Medicare rules. Evidence was provided to show that the annual maximum dental 
benefit amount of $750 has been met and exhausted. Based on this information, we decided that the Plan's rules 
for coverage of an unspecified adjunctive procedure and radiographic/surgical implant index have not been 
met. Therefore, we decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999) 
and radiographic/surgical implant index (D6190) provided by an out-of-network provider on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions of tooth #20, 21, 22, 25, 26, 27, and 28 
(D7140) provided on April 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should have been denied before the 
procedure was performed. The Plan denied your request. The Plan says your benefit for the requested items or 
services has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service April 5, 2022. 
Therefore, we decided that the Plan does not have to pay for the extractions of tooth #20, 21, 22, 25, 26, 27, 
and 28 (D7140) provided on April 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care on April 
01, 2021, to April 30, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing the enrollee is 
being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $184 copayment for each day for days 21 to 47 of skilled nursing facility (SNF) care. The provider 
billed the in the amount of $18364.16. The allowed amount is $1,2600. The enrollee is responsible for a $184 
copayment each day for days 21 to 47. $3,054.24 applied as the copayment and the plan paid $9545.76. 
Therefore, results in the total cost sharing amount of $3,054.24. 
 
 The enrollee has been asked to pay a $184 copayment each day for skilled nursing facility (SNF) care. Skilled 
nursing facility (SNF) care falls within the Skilled nursing facility (SNF) care benefit category. This means that 
the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for skilled nursing facility (SNF) care on April 01, 2021, to April 30, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on April 07, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for provider and professional services at specialists office. Covered services include consultation, 
diagnosis, and treatment by a specialist.  
 
You have been asked to pay a $45 copayment for office visit. Office visits fall within the Physician/practitioner 
services, including doctor's office visits 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 office visit on April 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral oral imaging 
(D0230) provided by a participating provider on June 16, 2021, and November 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 16, 2021. Two 
intraoral images were taken on June 16, 2021. The first image was paid for, the second intraoral image was 
denied due to frequency limitations. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) and intraoral oral imaging (D0230) provided by a participating provider on June 16, 2021, 
and November 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided from 
March 18, 2022, to March 30, 2022. 
 
You asked the Plan to waive the copayment for the inpatient rehab. You say that insurance should cover 20 
days of skilled nursing care. 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 $145 per 
day for days 1-4 and $0 per day for additional days for each inpatient admission.  
 
The file shows that you were in the rehab facility from March 18, 2022, to March 30, 2022. Therefore, you 
have been asked to pay $145 per day for days 1-4 of inpatient rehab. The total for your stay is $580 ($145 
copayment x 5 days = $580). The inpatient rehab falls within the Inpatient Hospital 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 inpatient rehabilitation care provided from March 18, 2022, 
to March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ECG provided on April 26, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an ECG. You say that these services were medically necessary. The Plan denied 
your request. The Plan says you must receive your care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
   
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 an ECG provided on April 26, 2022, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on April 21, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were informed by the 
doctor's office when scheduling this surgery that everything would be taken care of by your insurance, and you 
would have nothing to worry about. You also say that the copay is outside your current financial constraints. 
The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for ambulatory surgical center visits.  
 
You have been asked to pay a $300 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery, Including Services 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 outpatient surgery provided on 
April 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with codes A6530 and 
A6531 that were issued on March 8, 2022 and April 1, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says these items are not covered under 
your contractual policy or by Medicare for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. Additionally, the rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Additionally, the rules say that compression stockings described by code A6530 are noncovered because they 
do not meet the statutory definition of a surgical dressing. Therefore, we decided that the Plan does not have to 
pay for the compression stockings identified with codes A6530 and A6531 that were issued on March 8, 2022 
and April 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an overnight stay after surgery provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for an overnight stay after surgery. You say that you were told it 
was too late to go home after your surgery. Staff assured you that this would still be considered a same-day 
surgery. The Plan denied your request. The Plan says you were charged this cost sharing 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 an $850 
copayment for inpatient surgery.  
 
You have been asked to pay an $850 copayment for an overnight stay after surgery. An overnight stay after 
surgery falls within the Inpatient Surgery 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 overnight stay after surgery provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment of methadone provided 
from October 4, 2021, to October 25, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medication assisted treatment of methadone. You say that you are the only 
provider that provides these services within a 30-mile radius of the member's residence. The Plan denied your 
request. The Plan says the service was rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 medication assisted treatment of methadone 
provided from October 4, 2021, to October 25, 2021, by an out-of-network (OON) provider.