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

We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an abutment supported fixed denture (D6115) provided by a participating provider on July 14, 2021.

You asked the Plan to pay for a custom fabricated abutment and an abutment supported fixed denture. You say that you were told that dentures were covered. The Plan denied your request. The Plan says D6057 and D6115 are not covered dental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an abutment supported fixed denture (D6115) provided by a participating provider on July 14, 2021. 

The original decision letter was amended to include specific details from the contract regarding the dental benefit in the Medicare rules section which was omitted in error.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on December 9, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for laboratory work provided on December 9, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wellness visit provided on November 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wellness visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the wellness visit provided on November 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for renal dialysis services provided from July 
2, 2021, to November 1, 2021. 
 
You asked the Plan to waive the coinsurance for the renal dialysis services. You say that the services should be 
covered in full. The Plan denied your request. The Plan says the coinsurance applied correctly based on the 
services provided. 
 
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 Services to treat kidney disease.  
 
 You have been asked to pay a 20% coinsurance for renal dialysis services (total amount is $3,090.31). Renal 
dialysis services fall within the Services to treat kidney disease 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 renal dialysis services provided from July 2, 2021, to November 1, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99285) provided 
on July 9, 2021. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
provided. 
 
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 $120 
copayment for Emergency Care.  
 
 
 You have been asked to pay a $120 copayment for an emergency room visit. 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 emergency room visit (99285) provided on July 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray (72080) provided on October 12, 
2021. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered. The 
Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $15 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $15 copayment for an x-ray. X-rays fall 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 an x-ray (72080) provided on October 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second-level radiofrequency ablation (RFA) 
procedure. 
 
You asked the Plan to pre-approve a second level RFA procedure. 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 follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 second level RFA procedure. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the request for a 1-
level RFA procedure to L5-S1 has been approved. The review has determined that the enrollee does not meet 
the coverage criteria detailed in the LCD. 
 
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 second level RFA procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a second-level radiofrequency ablation (RFA) procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Inpatient stay from May 5, 2021 to May 
7, 2021. 
 
You asked the Plan to waive the copayment for Inpatient stay. You say that you want to dispute the copayment 
amount due to the horrible experience you had at the hospital. The Plan denied your request. The Plan says the 
copayment 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 $225 
copayment per day for an Inpatient stay.  
 
You have been asked to pay a $225 copayment per day for an Inpatient stay. An Inpatient stay 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 an Inpatient 
stay from May 5, 2021 to May 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for treatment of a bladder lesion (51720) 
provided from October 25, 2021 to November 8, 2021. 
 
You asked the Plan to waive the copayment for the treatment of a bladder lesion. You say that the services 
should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services provided. 
 
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 $250 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 You have been asked to pay a $750 copayment for three treatments of a bladder lesion. Treatments of a bladder 
lesion falls within the Outpatient Surgery and Other Medical 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 treatment of a bladder lesion (51720) provided from October 25, 2021 to November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 16, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee's physician ordered the testing, and 
the actual specimen to be tested are typically sent to you directly from the treating physician. You also say that 
you have no direct patient encounter, and therefore no means of knowing if a pre-authorization is required prior 
to you processing the specimen. The Plan denied your request. The Plan says the referral was not authorized by 
the primary care physician (PCP). The Plan also says that this provider is not a network provider with the Plan, 
and they have also determined 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 laboratory services provided on November 16, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work and hemodialysis provided on February 2, 
2021, to February 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work and hemodialysis. You say that the enrollee has been 
receiving treatment at this facility since November 2019. You say the services were medically necessary. The 
Plan denied your request. The Plan says the provider was out-of-network, and no prior authorization was 
obtained. 
 
 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance 
coverage and authorization. Therefore, we decided that the Plan does not have to pay for laboratory work and 
hemodialysis provided on February 2, 2021, to February 28, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza vaccination provided on December 14, 2021, 
by an out-of-network (OON) provider. 
 
 You asked the Plan to pay for the influenza vaccination. You say that you are a Medicare provider, and a 
primary care physician referral should not be required to process this claim. The Plan denied your request. The 
Plan says the provider is out-of-network. 
 
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 
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 influenza vaccination provided on December 
14, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an over-the-counter single vitamin purchased on  
February 1, 2021. 
 
You asked the Plan to pay for an over-the-counter single vitamin. The Plan denied your request. The Plan says 
you have not supplied additional information such as receipts showing you have paid for the over-the-counter 
single vitamin. 
 
The Plan contract covers a supplemental Over-the-Counter Items benefit. The Plan contract says send us your 
request for payment, along with your bill and documentation of any payment you have made. Its a good idea 
to make a copy of your bill and receipts for your records. We looked at the file and the Plans rules. The file shows that you have not supplied the Plan with additional 
information such as receipts showing you have paid for the item. Therefore, we decided that the Plan does not 
have to pay for an over-the-counter single vitamin purchased on February 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an ultrasound provided on September 22, 
2021. 
 
You asked the Plan to waive the deductible for the ultrasound. You say that the services should be covered. The 
Plan denied your request. The Plan says the deductible applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to Outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
the ultrasound was received on September 22, 2021. Therefore, we decided that the Plan does not have to 
waive the deductible for an ultrasound provided on September 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stress test and regadenoson injection 
provided on September 23, 2021. 
 
You asked the Plan to waive the copayment for the stress test and regadenoson injection. You say that the 
services should be covered. The Plan denied your request. The Plan says the coinsurance applied correctly 
based on the services provided. 
 
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 and Outpatient diagnostic tests and therapeutic services and 
supplies.  
 You have been asked to pay a 20% coinsurance for a stress test and regadenoson injection (total allowed is 
$1,087.77 x 20% = $217.55). Stress tests fall within the Outpatient diagnostic tests and therapeutic services and 
supplies benefit category and regadenoson injections fall within the Medicare Part B prescription drugs. 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 stress test and regadenoson injection provided on 
September 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgeries provided on July 8, 
2021, and August 12, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
provided. 
 
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 $250 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $500 copayment for two outpatient surgeries. 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 surgeries provided on July 8, 2021, and August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory work provided by a network 
facility on November 5, 2021. 
 
You asked the Plan to waive the copayment for the laboratory work. You say that the laboratory work should 
be included as a part of the annual physical. The Plan denied your request. The Plan says you have been asked 
to pay 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 $10 
copayment per day, per provider, for in-network Medicare-covered laboratory services.  
 You have been asked to pay a $10 copayment for the laboratory work. The laboratory work 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 laboratory work provided by a network facility on November 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue. 
 
You asked the Plan to pre-approve excision, excessive skin and subcutaneous tissue. 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 follows Medicare rules. Medicare rules say that abdominal lipectomy/panniculectomy are surgical 
removal of hanging excessive fat and skin in a transverse or vertical wedge from the abdomen but does not 
include muscle plication or flap elevation. This surgery is considered reconstructive when it is performed to 
alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the 
abdominal skin fold, or intertrigo dermatitis (dermatitis occurring on opposed surfaces of the skin, skin 
irritation, infection or chafing). 
 
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 excision, excessive skin and 
subcutaneous tissue. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the record indicates that you have undergone massive weight loss after bariatric surgery.  
 The record submitted does not indicate the presence of complicating factors such as, but not limited to, 
intertrigo refractory to conservative treatment or an inability to ambulate normally. The elements of the 
coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of excision, excessive skin and subcutaneous tissue have not been met. Therefore, 
we decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue.