Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the total electric hospital bed you received on April 8, 2021. 
 
You asked the Plan to pay for the total electric hospital bed.. You say that due to the pandemic, providers were 
closed and unable to get you the bed you wanted, so this should be covered. The Plan denied your request. The 
Plan says fully electric hospital beds are not covered as the height adjustment is a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital 
bed you received on April 8, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve 12 physical therapy visits. 
 
You asked the Plan to pre-approve 12 physical therapy visits. You say that you are worsening without proper 
care and have no one contracted within a 20-mile radius of your home. The Plan denied your request. The Plan 
says that physical therapy is denied due to lack of medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The requested 12 sessions need to be approved because we were not able to get 
any clarification from the Plan regarding what was approved versus what was denied at the time of the request. 
We are not able to make a determination on what additional services could be authorized without a clear 
description of the services that remain at issue after the partial approval was issued by the Plan. Therefore, we 
decided that the Plan has to pre-approve 12 physical therapy visits.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the chemodenervation of the facial nerves 
and the Botulinum toxin injections you received at an outpatient hospital facility on May 5, 2020. 
 
You asked the Plan to waive the cost sharing for the chemodenervation procedure and the Botulinum toxin 
injections. You say that you cannot afford this cost sharing. 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 a $150 
copayment for outpatient hospital services and 20% coinsurance for Medicare Part B drugs.  
 
You have been asked to pay a $150 copayment for the chemodenervation procedure and 20% coinsurance for 
the Botulinum toxin injections. The chemodenervation procedure falls within the outpatient hospital services 
benefit category. The Botulinum toxin injections are considered Medicare Part B drugs. This means that you 
have been asked to pay the correct amounts 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 cost sharing for the chemodenervation of the facial nerves and the Botulinum toxin 
injections you received at an outpatient hospital facility on May 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you $175 for your vision benefit for eyewear provided on 
May 26, 2021. 
 
You asked the Plan to reimburse you $175 for your vision benefit for eyewear. The Plan denied your request. 
The Plan says the claim was processed correctly based on your Evidence of Coverage. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every year. 
 
We looked at the file and the Plan's rules. The file shows that you received the vision benefit on  
December 16, 2020. The Plan says the vision coverage benefit is every year and it has been less than a year 
since you received the vision benefit. Therefore, we decided that the Plan does not have to reimburse you $175 
for your vision benefit for eyewear provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), and surgical tooth 
removal (D7210) provided by an out-of-network provider on May 12, 2021. 
 
You asked the Plan to pay for a panoramic radiographic image and surgical tooth removal. You say that this 
should be paid at a 50% coinsurance. The Plan denied your request. The Plan says this provider is not in-
network; therefore, these services have been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a panoramic 
radiographic image and surgical tooth removal when the services are provided by an out-of-network provider. 
When services are provided by an out-of-network provider, you may be asked to pay more. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a panoramic radiographic image and surgical tooth removal have been met for an out-of-network 
provider. The total amount you are being asked to pay is $439.35 ($74.35 (D0330) + $365 (D7210) = $439.35). 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330), and 
surgical tooth removal (D7210) provided by an out-of-network provider on May 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy services you received 
from April 2, 2021, to May 25, 2021. 
 
You asked the Plan to waive the copayments for the physical therapy services. You say that you were never 
told there would be a copayment for these services. The Plan denied your request. The Plan says you were 
charged these copayments 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 each outpatient rehabilitation service.  
 
You have been asked to pay a $20 copayment for the physical therapy services. The physical therapy services 
fall within the outpatient rehabilitation service benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayments for physical therapy services you received from April 2, 2021, to May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider from 
April 23, 2021, to May 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 services at issue in this appeal. 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 the services provided by an out-of-network provider from April 
23, 2021, to May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and to pay more 
for the complete series of intraoral x-rays (D0210) and prophylaxis (D1110) provided on June 30, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation or pay more for the complete series of 
intraoral x-rays and prophylaxis. You say that you asked your former dentist to forward x-rays and records to 
your new dentist, and he told you that you had not seen him in a year, and they would need new images. The 
Plan denied your request. The Plan says your benefits for the comprehensive oral evaluation have been satisfied 
and the frequency limitation has been exceeded. 
 
The Plan also says that the complete series of intraoral x-rays and prophylaxis were covered at the OON rate of 
50%, and you are responsible for the difference between the in-network fee schedule and the dentists' charged 
fee when visiting an OON dentist. 
 
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, comprehensive oral evaluation is 
limited to one procedure code every three years. The record shows that you received a comprehensive oral 
evaluation (D0150) on December 20, 2019 and your comprehensive oral evaluation benefit has been exhausted. 
The Plan contract also says that you are responsible for a 50% coinsurance for full mouth or panoramic x-rays 
and prophylaxis, plus the difference between the billed and allowed amount for the service being received 
OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
and to pay more for the complete series of intraoral x-rays (D0210) and prophylaxis (D1110) provided on June 
30, 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 rest home visit provided on April 30, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 rest home visit provided on April 30, 2021 by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
June 3, 2021, through June 7, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
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 $275 
copayment per day, for days 1-6 per benefit period for inpatient hospital care.  
Enrollees pay a $0 copayment per day for additional days. There are unlimited days for Medicare-covered 
stays. Additionally, enrollees are subject to a $1,925 maximum copayment. The copayment applies on the date 
of admission but not on the date of discharge.  
 
You have been asked to pay $1,100 ($275 copayment x 4 days) for the inpatient hospital care provided. 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 the inpatient hospital care provided from June 3, 2021, 
through June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that you have pain in your 
gums and they are bloody. You say that you are unable to chew and eat food which is affecting your qualify of 
life. The Plan denied your request. The Plan says periodontal scaling and root planing is not medically 
necessary. 
  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers periodontal 
scaling and root planing when the services are medically necessary and reasonable.  
 
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 periodontal scaling and root planing. 
Our physician reviewer found that there is no notable bone loss around any tooth in any quadrant except for 
tooth #31. Code D4341 is reserved for cases of periodontitis that involve four or more teeth in a quadrant and 
require cleansing of the affected root surfaces. Without loss of attachment, as noted by loss of bone support, 
there is no availability of the root surfaces to be scaled and cleaned. Our reviewer says that there is no medical 
necessity for the periodontal scaling and root planing at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling and root planing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve periodontal scaling and root planing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular panel testing provided on April 
20, 2021. 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says screening 
genetic testing is not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The records provided do not show that the testing was ordered due to a 
specific medical problem. The testing services were requested for screening purposes. Medicare does not cover 
this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary 
cardiovascular panel testing provided on April 20, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services (99285) provided 
on March 31, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that the services should be 
covered. The Plan denied your request. The Plan says the copayment applied 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 services. 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 (99285) provided on March 31, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmic biometry testing (92136) 
provided on July 16, 2021. 
 
You asked the Plan to waive the copayment for ophthalmic biometry testing. You say that there should be no 
charge. The Plan denied your request. The Plan says the copayment applied 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 $75 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  

You have been asked to pay a $52.42 copayment for ophthalmic biometry testing which is less than the $75 
stated in the Plan's contract. Ophthalmic biometry testing falls within the Outpatient diagnostic tests and 
therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ophthalmic biometry testing (92136) provided on July 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the CT scan provided on May 13, 2021. 
 
You asked the Plan to waive the deductible for the CT scan. You say that the only reason you had the CT scan 
done was because you had the coronavirus. 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. Your 
contract with the Plan says that there is $750 deductible which applies the CT scan.  
 
The CT scan you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and 
therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is $750 deductible that applies to the CT scan. This cost sharing is a contractual 
obligation that had not been met at the time the CT scan was received on May 13, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for CT scan provided on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory pathogen by nucleic acid testing for 
Chlamydia pneumoniae, cytomegalovirus, enterovirus, Herpes virus-6, Legionella pneumophila, Mycoplasma 
pneumoniae, Staphylococcus aureus, and six other organisms provided on September 8, 2020. 
 
You asked the Plan to pay for the extend viral pathogen panel. You say that the records submitted included all 
that the lab has access to which should support payment of this claim in full. The Plan denied your request. The 
Plan says these tests were billed with an inappropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the codes billed are not supported in the medical record. Specifically, the lab report submitted for 
review shows only results for a COVID-19 test. Results for the other pathogens billed are not present and 
cannot be verified as performed. Based on this information, we decided that Medicare rules for coverage of the 
extend viral pathogen panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory pathogen by nucleic acid testing for Chlamydia pneumoniae, cytomegalovirus, enterovirus, Herpes 
virus-6, Legionella pneumophila, Mycoplasma pneumoniae, Staphylococcus aureus, and six other organisms 
provided on September 8, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room care provided on May 26, 2021. 
 
You asked the Plan to pay for the emergency room care. The Plan denied your request. The Plan says the billed 
diagnosis does not represent an emergency. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  

We decided that this case does not meet prudent layperson criteria for emergency care. A prudent layperson 
would not reasonably expect the absence of immediate medical care to seriously jeopardize their health in this 
case. Therefore, we decided that the Plan does not have to pay for the emergency room care provided on May 
26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for OTC items provided on June 16, 2021. 
 
You asked the Plan to reimburse you for OTC items. You say that you cut off the bottom of each receipt to 
keep for your records. You say that you previously submitted other receipts without including the method of 
payment and they were approved and processed by the Plan. The Plan denied your request. The Plan says the 
receipt did not show the method of payment for items purchased. 
 
The Plan contract offers a supplemental Flex Benefit. The benefit say that each item listed on the claim form 
must include an itemized receipt(s) that shows the date of purchase/service, a description of item/service, the 
number of units purchased, the amount paid, proof of payment. Credit card statements are not proof of 
payment. 
 
We looked at the file and Plan rules. The file shows that you did not show the method of payment for the items 
purchased. Based on this information, we decided that the Plan's rules for coverage of OTC items have not 
been met. Therefore, we decided that the Plan does not have to reimburse you for OTC items provided on  
June 16, 2021.