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

 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and the intraoral-complete 
series of radiographic images (D0210) provided on October 10, 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 that you have exhausted the allowable benefit 
for these services. 
 
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. Specifically, the Plan provides supplemental coverage for two dental exams each 
calendar year. The Plan has stated that you exhausted the allowable benefit for these services as you previously 
received a dental exam on January 10, 2022 and February 8, 2022 accordingly. Additionally, the Plan provides 
coverage for an intraoral-complete series of radiographic images and a panoramic x-ray once every 60 months. 
The Plan has stated that you previously received a panoramic x-ray on February 24, 2021. However, the Plan 
has not provided substantive evidence that indicates payment was issued for these services provided. The Plan 
has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has 
to pay for the comprehensive oral evaluation (D0150) and the intraoral-complete series of radiographic images 
(D0210) provided on October 10, 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: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on February 17, 2022. 
 
You asked the Plan to pay for the emergency department visit.  The Plan denied your request. The Plan says 
that the Plan failed to make a reconsideration determination within the required CMS timeframe. 
 
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 Plan has not provided a Medicare or coding rule or a review to substantiate 
their denial. Therefore, we decided that the Plan has to pay for an emergency department visit provided on 
February 17, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services provided on May 11, 
2022. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you dont understand why you 
have a bill for this because you did not have this type of bill in the past. 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 $385 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay a $385 copayment for outpatient services. This item/service 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 outpatient services provided on 
May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a preventative procedure (D1999), gingivectomy (D4212), 
fabricated abutment (D6057), abutment support retainer crown (D6194), trigeminal division block anesthesia 
(D9212), and an adjunctive procedure (D9999) for tooth #19 and #21 provided on February 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services should be covered. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the preventative 
procedure, gingivectomy, fabricated abutment, abutment support retainer crown, trigeminal division block 
anesthesia, and adjunctive procedures are not covered by the Plan. 
 
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 pay for a 
preventative procedure (D1999), gingivectomy (D4212), fabricated abutment (D6057), abutment support 
retainer crown (D6194), trigeminal division block anesthesia (D9212), and an adjunctive procedure (D9999) 
for tooth #19 and #21 provided on February 9, 2022.
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 the enrollee meets LTACH criteria. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH. 
 
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 that the enrollee appears to be improving overall but with worsening anemia and 
should only require short-term additional acute care services that can safely be provided at the current facility 
until more stable and appropriate for a lower level of care. The enrollee does not require services at the 
LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary 
as it would not be clinically advantageous at this time. Completion of treatment at the current facility is 
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the outpatient hospital clinic visit provided 
on July 12, 2022. 
 
You asked the Plan to reduce the copayment for the outpatient hospital clinic visit. You say that this provider is 
your new PCP and the visit should only be a $5 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 $25 
copayment for physician/practitioner services, including doctors office visits (specialist). 
 
You have been asked to pay a $25 copayment for the outpatient hospital clinic visit. This item/service falls 
within the physician/practitioner services, including doctors office visits (specialist) 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. The place of service was 
billed as an outpatient hospital clinic, not the providers office. Therefore, we decided that the Plan does not 
have to reduce the copayment for the outpatient hospital clinic visit provided on July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on June 
21, 2022, to June 24, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you are disputing the 
share cost. 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 $795 
copayment for inpatient hospital care. 
 
You have been asked to pay a $795 copayment for inpatient hospital services. 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 services provided on June 21, 2022, to June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on April 04, 2022, to June 08, 
2022. 
 
You asked the Plan to pay for the office visits. You say that you were under the impression that your PCP had 
made a referral to this provider. 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 the office visits provided 
on April 04, 2022, to June 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on May 05, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you did not understand the provider could not bill 
for an office evaluation. 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 chiropractic care 
provided on May 05, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 5, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that you disagree with the Plan's denial. 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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 23, 
2022 to August 21, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services should be covered as the enrollee disagrees 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not meet 
the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from July 23, 2022 to August 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 16, 2022. 
 
You asked the Plan to pay for office visit. 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 office visit provided on 
September 16, 2022.
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 the enrollee's recovery would greatly 
benefit from an LTACH. The Plan denied your request. The Plan says all services that would be provided in the 
LTACH are being provided in the current acute care setting. 
 
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 that the enrollee appears to be stable and improving on current treatment and should 
only require short-term additional acute care services that can safely be provided at the current facility until 
more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that 
are not already available at the current facility. Transfer to the LTACH is not medically necessary as it would 
not be clinically advantageous at this time. Completion of treatment at the current facility is 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 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 Omnipods provided on September 19, 2022. 
 
You asked the Plan to pay for the Omnipods. You say that you are a diabetic and need this insulin pump and 
pods to control your blood sugar. You say that it would be dangerous for you not to be using the pods at this 
point. You say that this is being denied because it wasn't processed through the pharmacy. The Plan denied 
your request. The Plan says the supplies in dispute are not covered by Medicare as they are disposable and do 
not meet the definition of DME. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of DME. Drugs and supplies used with disposable drug delivery systems are also non-
covered items. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Omnipods have not been met. Therefore, we decided that the Plan does not have to pay for 
Omnipods provided on September 19, 2022.  
 
Benefits for the Omnipods may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a diagnostic colonoscopy provided on 
August 04, 2022. 
 
You asked the Plan to reduce the copayment for a diagnostic colonoscopy. You say that that the charges should 
be limited to the expected $30 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 $200 
copayment for ambulatory surgical service. 
 
You have been asked to pay a $200 copayment for a diagnostic colonoscopy. This item/service falls within the 
ambulatory surgical 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 reduce the copayment for a 
diagnostic colonoscopy provided on August 04, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they do not meet the 
clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the medical record supports a need for physical and/or occupational therapy, but 
that there is no documented need for intensive rehabilitation services. The enrollees needs can be provided at a 
lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2751) provided on March 18, 2021, a crown 
(D2920) provided on June 7, 2022, a consultation (D9310), and crown recement (D2920) provided on 
September 8, 2022. 
 
You asked the Plan to pay more 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 crown has already 
been exhausted and services for a consultation (D9310) and crown recement (D2920) denied correctly as they 
do not fall within your dental 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 18, 2021. 
Therefore, we decided that the Plan does not have to pay more for a crown (D2751) provided on March 18, 
2021, a crown (D2920) provided on June 7, 2022, a consultation (D9310), and crown recement (D2920) 
provided on September 8, 2022.