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

 
We decided that the Plan does not have to pay for the crown (D2740) for tooth # 8 provided on November 15, 2021. 
 
You asked the Plan to pay for the dental service. You say that you experienced a fall. You say that 2 teeth were 
broken off and needed to be repaired so they would last permanently. You say that this was not cosmetic but 
was the result of a bad fall. You also say that you do not understand why this is not covered medically. The 
Plan denied your request. The Plan says the claim denied correctly. 
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 crown for tooth # 8 is not among 
those covered under this benefit. Additionally, the services you are asking the Plan to pay for involve the care, 
treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These 
are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not 
have to pay for the crown (D2740) for tooth # 8 provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D photographic image (D0350), and adjunctive 
prediagnostic test (D0431) provided on December 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were assured by the dentist and associates 
that your plan would cover part of this charge. The Plan denied your request. The Plan says the services denied 
correctly. 
 
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 2D photographic images and 
adjunctive prediagnostic test are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D photographic image (D0350), and adjunctive prediagnostic test (D0431) 
provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound and specialist visit provided 
on November 23, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound and specialist visit. You say that this is the first 
time you've had 2 copayments in one doctor's visit for the same provider. The Plan denied your request. The 
Plan says the copayment was 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 $25 
copayment for ultrasounds and a $20 copayment for specialist visits.  You have been asked to pay a total of $45 for the ultrasound and specialist visit. An ultrasound falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. Specialist visits fall within 
the Physician/Practitioner services, including doctors office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the ultrasound and specialist visit provided on November 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mental health telehealth visit provided on 
October 11, 2021. 
 
You asked the Plan to waive the copayment for a mental health telehealth visit. The Plan denied your request. 
The Plan says you have been charged 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 $40 
copayment for an outpatient mental health telehealth visit.  
 
You have been asked to pay $35, which is less than the $40 copayment for a mental health telehealth visit. A 
mental health telehealth visit falls within the Telehealth 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 a mental health telehealth visit provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit and transitional care 
management services provided on December 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit and transitional care management services. You 
say that at the time of service, the member was residing at the facility and therefore, the rendering provider was 
not responsible to obtain authorization. You also say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients, which should also cover for the medical treatment provided by the 
rendering provider. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, 
and authorization was not obtained prior to the services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit and transitional 
care management services provided on December 8, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from August 27, 
2020, to December 22, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. The Plan denied your request. The Plan says valid 
proof of payment for the services provided from September 14, 2020, to December 22, 2020 has not been 
received. 
 
The Plan must follow Medicare rules. Medicare rules say that you must submit proof of payment to the Plan for 
reimbursement. 
 
We looked at the file and Medicare rules. No proof of payment has been submitted. Based on this information, 
we decided that Medicare rules for coverage of the inpatient hospital services have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient hospital services provided from August 27, 2020, to 
December 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medication therapy provided on 
November 4, 2021. 
 
You asked the Plan to waive the copayment for nuclear medication therapy. You say that the services were part 
of an approved authorization and 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 $100 
copayment for in-network nuclear medicine at an outpatient hospital for nuclear medication therapy.  
 
You have been asked to pay $100 for nuclear medication therapy. Nuclear medication therapy falls within the 
Nuclear medicine 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 nuclear medication 
therapy provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330), and the removal of benign 
odontogenic cyst (D7450) provided by a participating provider on November 16, 2021, to November 23, 2021. 
 
You asked the Plan to pay for panoramic imaging and the removal of benign odontogenic cyst. You say that 
you needed this dental work done. The Plan denied your request. The Plan says D0330 and D7450 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 
panoramic imaging (D0330), and the removal of benign odontogenic cyst (D7450) provided by a participating 
provider on November 16, 2021, to November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 29, 2021. We also decided that the Plan does not have to waive the copayments for specialist visits 
provided on November 5, 2021, and December 16, 2021. 
 
You asked the Plan to waive the copayments for the specialist visits. You say that you were informed there 
would be no copayments during COVID-19. The Plan denied your request. The Plan says you have been 
charged 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 $30 
copayment for each specialist visit, including telehealth services.  
 
You have been asked to pay a $30 copayment for each of the specialist visits. Please note that there were no cost share waivers in effect for COVID-19 at the times of service. The specialist visits fall within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit provided on December 29, 2021. We also decided that the 
Plan does not have to waive the copayments for specialist visits provided on November 5, 2021, and December 
16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blood glucose test or reagent strips for home blood 
glucose monitor (A4253) and lancets (A4259). 
 
You asked the Plan to pre-approve diabetic supplies. You say that you get dizzy and requested medical supplies 
to test your blood sugar levels. The Plan denied your request. The Plan says no diagnosis of diabetes was ever 
documented, and the provider has not confirmed you have diabetes. 
 
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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections and require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of diabetic supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve blood glucose test or reagent strips for home blood glucose monitor (A4253) 
and lancets (A4259).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures provided on July 28, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic procedures. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says a prior authorization was not obtained by the out-of-network 
provider for the services rendered on July 28, 2021. The Plan also says that the provider did not submit any 
documentation that the procedures were part of an emergency 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 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 therapeutic procedures provided on July 28, 2021, 
by an out-of-network (OON) provider.
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 you do not have strength to live on your own. The 
Plan denied your request. The Plan says you can safely receive services in another setting. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for congestive heart failure. Your medical problems are stable. 
The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 21, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says there is no referral from the primary care provider (PCP) 
for the rendering provider for date of service, October 21, 2021, as the patient was last seen, April 21, 2021. 
The Plan also says that the services were billed by/rendered by non-participating providers. The Plan also says 
that 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 a domiciliary or rest home visit provided on 
October 21, 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 the dental cleaning (D1110), comprehensive exam (D0150) 
and bitewing x-rays (D0274) provided on January 3, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the last time you checked, you saw that you 
could use out-of-network providers, and you were not informed that your benefits would change in 2022. The 
Plan denied your request. The Plan says your dental benefit does not include out-of-network benefits, and the 
provider in this case is out-of-network. The Plan also says that when you called in November, you did not 
advise that you were looking to have the services provided in 2022, and you were mailed your 2022 Annual 
Notice of Changes in September 2021, which detailed the upcoming changes in your dental benefit. 
 
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, items or services received from out-of-
network providers are not covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the dental cleaning (D1110), comprehensive exam (D0150) and bitewing x-rays (D0274) provided on 
January 3, 2022, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit on December 7, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you do not agree with the copayment assessed for your out-of-pocket maximum. The Plan denied your request. The Plan says you had not met the out-of-pocket maximum therefore, the copayment assessed is correct.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay $35 for copayment for a specialist visit. You have been asked to pay a $35 copayment for the office visit. An office visit falls within "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on December 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on April 26, 2021, 
through April 30, 2021. 
 You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration 
because the documentation supports the DRG billed. The Plan denied your request. The Plan says the record 
does not support diagnosis code E43. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 919 with secondary diagnosis code E43. 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 the inpatient hospital services. Our reviewer 
says that the documentation submitted does not sufficiently support DRG 919 with secondary diagnosis code 
E43 (Unspecified severe protein-calorie malnutrition). Our physician reviewer found there was no objective 
measurements of this weight loss or malnourishment to support this diagnosis. He weighed 150 lbs, BMI 22. 
There was no documentation of muscle wasting and no specifics on percentage of eaten protein/calories 
compared to requirements. Protein level of in normal range during hospitalization.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on April 26, 2021, through April 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
December 8, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that you thought the Plan should have paid 
the bill. The Plan denied your request. The Plan says you have been charged 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 $95 
copayment for diagnostic procedures and tests in an outpatient hospital.  
 
You have been asked to pay $62.59, which is less than the $95 copayment for the ECG. The ECG 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 an electrocardiogram (ECG) provided on December 8, 2021.