Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on December 04, 2021. 
 
You asked the Plan to waive the copayment for ER visit. You say that this should be covered. 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 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 ER visit provided on December 
04, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment of methadone (G2067) 
provided on July 11, 2022. 
 
You asked the Plan to pay for medication assisted treatment of methadone (G2067). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says services were billed by a non-
physician practitioner who cannot bill directly, or services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that registered nurses (RN) are not eligible to enroll 
in Medicare. The rules also say that to receive payment for covered Medicare items or services from either 
Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the Medicare program.  
 
 
  We looked at the file and Medicare rules. The rules say that RNs who provide service can only do so under a 
physician or other valid practitioner, so the physician would have to be listed as the rendering provider. 
Providers who want to get paid have to be enrolled in the Medicare program, and an RN is not eligible to enroll 
in Medicare. Therefore, an RN cant be paid. Based on this information, we decided that Medicare rules for 
coverage of medication assisted treatment of methadone (G2067) have not been met. Therefore, we decided 
that the Plan does not have to pay for medication assisted treatment of methadone (G2067) provided on July 
11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 05, 2022. 
 
You asked the Plan to pay for lab services. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
October 05, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Huntington (HTT) gene analysis (81271, 81274). 
 
You asked the Plan to pay for genetic testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing submitted under CPT codes 
81271 and 81274 are unlikely to impact therapeutic decision-making in the clinical management of the patient 
and will be automatically denied as not medically necessary. 
 
We looked at the file and Medicare rules. The codes submitted, 81271 and 81274 and not covered. Based on 
this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for Huntington (HTT) gene analysis (81271, 81274).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia provided on March 10, 2022. 
 
You asked the Plan to pay for anesthesia. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for anesthesia provided on 
March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the cervical spine (72040), mechanical 
traction therapy (97012), and the extra-spinal chiropractic manipulative treatment (98943) provided from 
March 21, 2022, through May 24, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the x-ray exam of the cervical spine (72040), mechanical traction therapy 
(97012), and the extra-spinal chiropractic manipulative treatment (98943) provided from March 21, 2022, 
through May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on September 
17, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that this should be covered. 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 $20 
copayment for lab services. 
 
You have been asked to pay a $20 copayment for laboratory services. This item/service falls within the lab 
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 laboratory services 
provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the extraction, of an erupted tooth or 
exposed root (D7140) and the repair of a resin partial upper denture base (D5612) provided on September 26, 
2022. 
 
You asked the Plan to issue reimbursement for these dental services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided are not covered under this benefit when 
received from an out-of-network provider. Additionally, you did not request prior authorization for these 
services.  
 Therefore, we decided that the Plan does not have to issue reimbursement for the extraction, of an erupted tooth 
or exposed root (D7140) and the repair of a resin partial upper denture base (D5612) provided on  
September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on September 15, 2022. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for surgery provided on 
September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the bridge with crown build up provided on September 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the enrollee has not previously had this 
procedure covered through dental insurance. The Plan denied your request. The Plan says that your benefit for 
the requested item or service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. There is no 
evidence showing your benefit for the requested item or service was previously exhausted. The record shows 
the Plan did not cover the initial bridge, so a frequency limit does not apply. Therefore, we decided that the 
Plan has to pay for the bridge with crown build up provided on September 22, 2022.  
 
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 waive the coinsurance for laboratory services provided on August 
17, 2022. 
 
You asked the Plan to waive the coinsurance for laboratory services. You say that you had reached your out-of-
pocket maximum so this should be covered. 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 15% 
coinsurance for Lab services. 
 
You have been asked to pay 15% coinsurance for laboratory services. This item/service falls within the Lab 
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 coinsurance for laboratory services 
provided on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the foot, plastic, silicone or equal, heel stabilizers (L3170 x 2), ankle 
foot orthoses (L1971 x 2), and the spinal orthosis (L0457) provided on June 1, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says that the items at issue are not payable. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
We looked at the file and Medicare rules. The record does contain a valid physician order, proof of delivery, 
and relevant medical records which support the medical necessity for the supplies provided in this case. 
Therefore, we decided that the Plan has to pay for the foot, plastic, silicone or equal, heel stabilizers  
(L3170 x 2), ankle foot orthoses (L1971 x 2), and the spinal orthosis (L0457) provided on June 1, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on September 28, 2022, billed 
under codes 14041, 17311 and 17312. 
 
You asked the Plan to pay for outpatient surgery. You say that you received a referral from your primary care 
provider, so this surgery should be covered. The Plan denied your request. The Plan says we do not have 
evidence that the coverage criteria were met. The Plan says that they made reasonable attempts to obtain 
medical records from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of outpatient surgery have been met. 
There were no medical records provided. Without this necessary information, we are unable to determine 
whether the criteria for coverage have been met and whether payment is due. The Plan has shown that they 
made reasonable attempts to obtain this necessary information. Therefore, we decided that the Plan does not 
have to pay for outpatient surgery provided on September 28, 2022, billed under codes 14041, 17311 and 
17312.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that this item was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from May 11, 2022 to July 28, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says per Medicare, the 
provider must attempt to consult the attending or primary care physician about the services furnished and 
document the consent or declination date to consultations and the date of consultations in the patients medical 
record. If consultation with the attending or primary care physician is unsuccessful, document the patients medical chart with the date and manner of notification to the physician. There was no documented contact with 
the attending/primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from May 11, 2022 to 
July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supply provided on 
September 15, 2022. 
 
You asked the Plan to pay for CGM supply. You say that you are appealing with proof of delivery. The Plan 
denied your request. The Plan says the records submitted do not include valid proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Specifically, the record does not include evidence of 
successful delivery to the enrollees specific address. Therefore, we decided that the Plan does not have to pay 
for continuous glucose monitor (CGM) supply provided on September 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
November 08, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you shouldnt have to pay 
for 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 $45 
copayment for specialist visits. 
 
You have been asked to pay a $45 copayment for specialist office visit. This item/service falls within the 
specialist 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. You have been asked to pay $39.76 which is less than the standard $45 copayment for a specialist visit. 
Therefore, we decided that the Plan does not have to waive the copayment for specialist office visit provided on 
November 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on October 11, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on October 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
September 21, 2022, to October 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with 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 $225 
copayment per day for days 1-7 for inpatient hospital care.  
 
You have been asked to pay a $225 copayment per day for days 1-7 for inpatient hospital care. The total 
amount you are being asked to pay $1,575 ($225 x 7days = $1,575). This item/service 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 hospital care 
provided on September 21, 2022, to October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided from February 10, 2022 to  
August 5, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the office visits. You say that you were never informed that this provider is 
out-of-network. The Plan denied your request. The Plan says your Plan excludes coverage for this out-of-
network service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for office visits provided from February 10, 2022 to August 5, 2022, 
by an out-of-network provider.