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

 
We decided that the Plan does not have to pre-approve a prefabricated post and core (D2954), endodontic 
therapy (D3320), cone beam CT capture (D0364), a core build-up (D2950), pontic (D6245), a custom 
fabricated abutment (D6057), an abutment supported crown (D6068), and a bone graft (D6104), provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve a prefabricated post and core, endodontic therapy, cone beam CT capture, a 
core build-up, pontic, a custom fabricated abutment, an abutment supported crown, and a bone graft. You say 
that you cannot eat properly. The Plan denied your request. The Plan says the requested services are not 
covered 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 a 
prefabricated post and core (D2954), endodontic therapy (D3320), cone beam CT capture (D0364), a core 
build-up (D2950), pontic (D6245), a custom fabricated abutment (D6057), an abutment supported crown 
(D6068), and a bone graft (D6104), provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit provided on May 11, 2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that you cannot afford this charge. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $25 
copayment for Telehealth specialist visit. 
 
You have been asked to pay a $25 copayment for telehealth visit. This item/service falls within the Telehealth 
specialist visit 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 telehealth visit provided 
on May 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on June 19, 
2022, to June 28, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this is causing financial 
hardship and you cannot to pay this. The Plan denied your request. The Plan says this cost sharing was charged 
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 $125 
copayment for Ambulance Services. 
 
You have been asked to pay a $125 copayment for ambulance transport. This item/service 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. You are being asked to pay $250 ($125 per trip) for the ambulance transport. Therefore, we 
decided that the Plan does not have to waive the copayment for ambulance transport provided on June 19, 
2022, to June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for specialist office visit provided on July 05, 
2022. 
 
You asked the Plan to reduce the copayment for specialist office visit. You say that this should only be a $10 
copayment and not $30. The Plan denied your request. The Plan says this cost sharing was charged 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 $30 
copayment for Specialist office visits. 
 
You have been asked to pay a $30 copayment for specialist office visit. This item/service falls within the 
Specialist 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 reduce the copayment for specialist 
office visit provided on July 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 tests provided on May 28, 2022. 
 
You asked the Plan to pay for over-the-counter COVID-19 tests. You say that these were COVID-19 tests. The 
Plan denied your request. The Plan says Medicare members can obtain up to eight Federal Drug Administration 
(FDA)-authorized over-the-counter Covid-19 tests every calendar month without a prescription and at no cost, 
through pharmacies and providers that participate in the testing program offered through the federal Medicare 
program. The Plan also says that this program is administered by the Centers for Medicare and Medicaid 
Services (CMS), and all testing reimbursement is through the federal Medicare program. The Plan also says 
that they cannot reimburse members who pay out of pocket for tests under this program. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will cover up to eight over-the counter 
COVID-19 tests each calendar month at no cost to you. Medicare will also cover these tests if you have Part B, 
including those enrolled in a Medicare Advantage (MA) plan. If you are under an MA plan, the tests covered 
under this initiative will be covered outside of your existing plans coverage.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of over-the-counter COVID-19 tests have not been met. Therefore, we decided that the Plan does not 
have to pay for over-the-counter COVID-19 tests provided on May 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for anti-reflective coating (V2750) and 
polycarbonate lens (V2784) provided on April 4, 2022. 
 
You asked the Plan to waive the copayment for anti-reflective coating (V2750) and polycarbonate lens 
(V2784). You say that you were told that you have an eyeglass benefit of $200 that would cover the cost. You 
also say that you have a bill for $13.75, and you do not feel that is your responsibility. The Plan denied your 
request. The Plan says this cost sharing was charged 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 $65 
copayment for standard and premium progressive lenses and standard anti-reflective coating.  
 You have been asked to pay $13.75, which is less than the $65 copayment for anti-reflective coating (V2750) 
and polycarbonate lens (V2784). This item/service falls within the standard and premium progressive lenses 
and standard anti-reflective coating benefit category. The record shows these are upgraded lenses. 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 anti-reflective coating (V2750) and polycarbonate lens (V2784) 
provided on April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathogen panel testing provided on December 29, 2021. 
 
You asked the Plan to pay for the testing services. You say that the provider deemed the services medically 
necessary. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  The file shows that a respiratory panel test with 12-25 targets was provided. We looked at the file, and 
Medicare rules. Panels with more than 5 pathogens are not considered medically necessary. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the pathogen panel testing provided on December 29, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on July 
14, 2022, to July 15, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you are asking the plan 
to pay for the for the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
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 in-network emergency care.  
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
in-network emergency 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 emergency 
room services provided on July 14, 2022, to July 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on December 13, 2021. 
 
You asked the Plan to pay for the testing services. You say that the codes were not processed at the full 
amount. The Plan denied your request. The Plan says the coding is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the lab testing services provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatrist services provided to the enrollee on May 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that these services are not urgent or emergent, nor were they 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 podiatrist services provided to the enrollee on 
May 16, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room (ER) visit provided on 
April 19, 2022. 
 
You asked the Plan to waive the copayment for emergency room (ER) visit. You say that you were just getting 
stiches out so you shouldnt be charged. The Plan denied your request. The Plan says this cost sharing was 
charged 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 care. 
 
You have been asked to pay a $90 copayment for emergency room (ER) visit. This item/service falls within the 
Emergency 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 emergency room 
(ER) visit provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 May 2, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 67820 billed for date of service June 28, 
2022. 
 
You asked the Plan to pay for procedure code 67820. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 67820 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 67820 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 67820 billed for date of service June 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan provided on January 14, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a CT scan. You say that this test is needed based on medical necessity and is 
asking the plan to reconsider payment. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 a computed tomography (CT) scan provided on 
January 14, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have severe chronic obstructive pulmonary disease (COPD), and arterial blood gases (ABG) 
shows chronic carbon dioxide (CO2) retention. You may benefit from bilevel positive airway pressure (BiPAP) 
with average volume-assured pressure support (AVAPS) during sleep. But Medicare does not cover a home 
ventilator when used as BiPAP.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the most appropriate setting 
for the enrollee. The Plan denied your request. The Plan says the denial of authorization for LTACH care is 
correct. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found all medically necessary care is being provided in the current setting. The enrollee 
does not require services at the LTACH that are not available at the current health care setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has severe chronic obstructive pulmonary disease (COPD), but there is no 
documentation of chronic carbon dioxide (CO2) retention with an arterial blood gas (ABG) done while stable. 
If the enrollee does have chronic CO2 retention, bilevel positive airway pressure (BiPAP) with average 
volume-assured pressure support (AVAPS) may be of benefit. But Medicare does not cover a home ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150) and a 
complete intraoral x-ray series (D0210) provided on March 9, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told that the provider you saw 
took your insurance. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from 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. 
 
You have been asked to pay a total of $140, which is the difference between the out-of-network providers 
charges and the Plans payment. 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 pay more for a comprehensive oral 
evaluation (D0150) and a complete intraoral x-ray series (D0210) provided on March 9, 2022.