Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on August 01, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that the services were for a post-
operation and that you should not have to pay it. 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 $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls 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 an office visit provided on August 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and deductible for the crown (D2750) for 
tooth #30 provided on May 18, 2022. 
 
You asked the Plan to waive the coinsurance and deductible for the dental service. You say that you feel that 
the Plan should pay for the dental service. 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 50% 
coinsurance for prosthodontics (partial dentures, crowns) in-network and out-of-network and a $100 deductible 
per calendar year. The total allowed amount for the crown was $648.35 with a coinsurance of $324.18 ($648.35 
total amount x 50% coinsurance). Prior to the date of service the total amount paid towards the yearly 
deductible was $47.84 leaving $52.16 ($100 yearly deductible - $47.84 paid towards deductible) to pay 
towards the yearly deductible. The total cost share amount for the crown was $376.34 ($324.18 coinsurance + 
$52.16 deductible). 
 
You have been asked to pay a 324.18 coinsurance and a $52.16 deductible for the dental service. This 
item/service falls within the dental services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
and deductible for the crown (D2750) for tooth #30 provided on May 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 27, 
2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the enrollee had no other 
optional modes of transportation. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for ambulance services.  
 
The enrollee has been asked to pay a $250 copayment for the ambulance services. This item/service falls within 
the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance services provided on August 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0120) and adult prophylaxis (D1110) 
provided on May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you wish to have the liability removed from you 
being subject to pay this expense. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider. The Plan says you are responsible for the difference between the in-
network fee schedule and the dentist's charged fees when visiting an out-of-network dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered in full 
under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for an oral evaluation (D0120) and adult prophylaxis (D1110) provided on May 2, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room visit and magnetic 
resonance imaging (MRI) provided from July 23, 2022, to September 9, 2022. 
 
You asked the Plan to waive the copayments for ER visit and MRI. You say that you want to know what's 
going on with these claims. 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 $90 
copayment for ER visit and $100 copayment for MRI. Your total copayment amount is therefore $190. 
 
You have been asked to pay $90 copayment for ER visit and $100 copayment for MRI. These items/services 
fall within the "Emergency Care" and "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit categories. 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 an emergency room visit and 
magnetic resonance imaging (MRI) provided from July 23, 2022, to September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft on tooth #7 (D7953), guided tissue 
regeneration on tooth #7 (D4266), and an endosteal implant on tooth #7 (D6010) provided on October 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you only wanted your tooth replaced. The Plan 
denied your request. The Plan says that a bone replacement graft (D7953), guided tissue regeneration (D4266), 
and an endosteal implant (D6010) are not covered by 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, 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 bone 
replacement graft on tooth #7 (D7953), guided tissue regeneration on tooth #7 (D4266), and an endosteal 
implant on tooth #7 (D6010) provided on October 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on November 15, 2022. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry visit provided on September 30, 2022. 
 
You asked the Plan to pay for podiatry 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 podiatry visit provided 
on September 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office sandwich to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit.. You say that this should be covered. The Plan denied your 
request. The Plan says you must see providers that are in-network. This only applies to certain scenarios. There 
was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network 
(OON) provider or facility, and this was not an emergency. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office sandwich to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), 
custom abutments (D6057), and an abutment supported to a metal crown (D6059) for tooth #29 and #30. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services and would like them to be covered. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because dental implants and all associated services 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 pre-approve the 
surgical placement of implant body (D6010), custom abutments (D6057), and an abutment supported to a metal 
crown (D6059) for tooth #29 and #30.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Computed Tomographic Angiography (CTA) services. 
 
You asked the Plan to pre-approve the CTA services. You say that the clinical notes provided support the need 
for the CTA services in dispute. The Plan denied your request. The Plan says that the provider did not order the 
correct Current Procedural Terminology (CPT) codes to assess for peripheral arterial disease. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CTA services. Our reviewer says 
that the criteria for coverage of CTA services have been met. Our physician reviewer found the enrollee has 
diabetes mellitus and known coronary artery disease.  His physical exam revealed present but diminished 
pulses dorsalis pedis and posterior tibial arteries.  He has a smoking history.  For all these reasons the 
possibility of peripheral vascular disease is very likely. A CTA of the abdominal aorta and iliac arteries with 
runoff is medically necessary. 
 
While the CPT code used in the request was incorrect in representing the type of CTA needed, coding 
arguments should not be used to determine whether a requested service can or should be covered. As the 
provider is noted to be in-network, it is expected that the Plan would work with its provider to determine what 
codes are correct for a given service. An enrollee should not be denied access to covered services due to the 
network provider requesting the wrong code. We looked at our physician's review, the file, and Medicare rules.  
Based on this information, we decided that Medicare rules for coverage of the CTA services have been met. 
Therefore, we decided that the Plan has to pre-approve Computed Tomographic Angiography (CTA) of the 
abdominal aorta and iliac arteries with runoff.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 pre-approve 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 the enrollee had coronary by-pass. On February 21, 2023, the enrollee was 12 days 
post-op and modified independent to supervision for transfers and ambulation. The enrollee walked 200ft. The 
enrollee is functioning at a home care to community level of rehabilitation. Daily skilled services are not 
medically necessary. No daily skilled nursing needs. 
 
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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (CPT 78816). 
 
You asked the Plan to pay for the scan. You say that this is medically necessary. The Plan denied your request. 
The Plan says based on the additional information available, the request does not meet the Medicare or health 
plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
already had three PET/computed tomography (CT) scans. Another one cannot be approved. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a positron emission tomography (PET) scan (CPT 78816).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to an IRF is not medically necessary. 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for COVID-19 treatment received on October 25, 2021. 
 
You asked the Plan to pay for the treatment. You say that this service should be reimbursed. The Plan denied 
your request. The Plan says that this should not have been billed. 
 
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 is denying this service based on the fact that it's a COVID-19 
vaccination. The denied service is intended for treatment of COVID-19. The plan has not forwarded a valid 
denial based on what the services actually are. The plan has not fully specified what they are basing the denial 
on. Therefore, we decided that the Plan has to pay for COVID-19 treatment received on October 25, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next test strips. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from the preferred provider.  
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The requested items are from a non-preferred provider. The services 
are available from one of the Plans preferred providers. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Contour Next test strips.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on November 07, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that this should be covered. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for ER visit. This item/service falls within the emergency care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for ER visit provided on November 
07, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 92542, 92544 and 92541 billed for date of 
service May 23, 2022. 
 
You asked the Plan to pay for procedure codes 92542, 92544 and 92541. You say that the claim was billed 
correctly and should be paid. The Plan denied your request. The Plan says payment for code 92544 and 92542 
is bundled into payment for code 92541. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that only certain physician 
services are payable when provided via telehealth. 
 
In this case, we have confirmed from the documentation on the CMS website that code 92541 is not a code that 
is eligible for payment in the telehealth setting. We have also confirmed that code 92544 and 92542 is a 
column II code to column I code 92541. This claim has not been billed with an appropriate modifier to bypass 
the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 92542, 92544 and 92541 billed for date of service May 23, 
2022.