Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 22, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 5, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain/ceramic (CPT code D6740), 
core buildup, including any pins when required (D2950) and pontic - porcelain/ceramic (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says there is no indication that there is insufficient tooth structure under the 
existing crown for tooth #14. 
 
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 dental services. Our physician 
reviewer found the Plan specifies that full coverage restorations are not a covered service unless " D. When 
the abutment tooth has at least 50% remaining bone support. In this instance, #14 has more than 50% bone 
loss on the distal aspect. Tooth #11 has closer to 70% bone loss and would not be viable for supporting a bridge 
from #11-14.  The Plan criteria for a crown or bridge abutment has not been met. 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 dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
retainer crown - porcelain/ceramic (CPT code D6740), core buildup, including any pins when required (D2950) 
and pontic - porcelain/ceramic (D6245).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that you needed diagnosis codes from the provider. The 
Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until June 29, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 28, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
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 laboratory services 
provided on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on June 30, 2022. 
 
You asked the Plan to pay for rest home visit. You say that you are appealing the claim payment denial. 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 rest home visit provided 
on June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brain imaging, positron emission tomography (PET) 
scan; metabolic evaluation (78608). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that a Fluorodeoxyglucose (FDG) Positron Emission 
Tomography (PET) scan is considered reasonable and necessary in patients with a recent diagnosis of dementia 
and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimers 
Disease (AD) and Frontotemporal Dementia (FTD). 
 
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 this service. Our reviewer says that the 
requested service is not medically necessary.  Our physician reviewer found that in this case, the records provided for review did not demonstrate that the 
enrollee met diagnostic criteria for either Alzheimers Disease or Frontotemporal Dementia. As such, the 
diagnostic criteria of the primary conditions for which this service may be covered, have not been satisfied. 
This request does not meet Medicare requirements for coverage.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a brain imaging, positron emission tomography (PET) scan; metabolic evaluation (78608).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic continuous glucose monitor (CGM) supplies 
provided on March 9, 2022. 
 
You asked the Plan to pay for therapeutic CGM supplies. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says proof of delivery was not submitted to support payment 
of this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that proof of delivery is required to support payment 
for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).  
 
We looked at the file and Medicare rules. Proof of delivery for the billed items has not been submitted to the 
Plan. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM supplies 
have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic continuous glucose 
monitor (CGM) supplies provided on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on September 30, 
2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. 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/practitoner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for office visit. This item/service falls within the 
physician/practitoner 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 office visit provided on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on August 22, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you would like to appeal this service. The Plan 
denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers refractions when performed during a routine vision exam. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you were seen for multiple 
diagnoses at this appointment. This visit was medical based, and not a routine exam. Based on this information, 
we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided 
that the Plan does not have to pay for the eye refraction (92015) provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 11, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. 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 visit provided 
on May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a breast procedure provided on July 22, 2022. 
 
You asked the Plan to pay for a breast procedure. You say that this was medically necessary and should be 
covered. 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 a breast procedure 
provided on July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye exam provided on August 18, 2022. 
 
You asked the Plan to pay for eye exam. You say that you did not know you needed a referral from your 
primary care physician. 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 eye exam provided on 
August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified removable prosthodontic procedure (D5899) 
provided on August 25, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the requested services covered 
because you had two teeth that broke. The Plan denied your request. The Plan says this service is not covered 
under your 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. Unspecified removable 
prosthodontic procedure (D5899) are not covered under the Plans dental benefits. 
 
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 
unspecified removable prosthodontic procedure (D5899) provided on August 25, 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 
30, 2022, to July 2, 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 $200 
copayment for inpatient hospital care.  
 
You have been asked to pay $164.38 which is less than the $200 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 30, 2022, to July 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (A4595) billed for date of 
service June 11, 2022. 
 
You asked the Plan to pay for electrical stimulator supplies. You say that the items at issue were billed 
correctly. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
documents provided as proof of delivery do not sufficiently identify the items delivered as the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for electrical 
stimulator supplies (A4595) billed for date of service June 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 21, 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 
May 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on September 9, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
the proof of delivery date of service is different than the date of service submitted on the claim for payment. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment provided on September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950), a pontic (D6245), and retainer 
crowns (D6740) for tooth #8, #9, and #10 
 
You asked the Plan to pre-approve the dental services. You say that you fell and busted your teeth and need the 
dental procedures approved. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because core buildup, pontics, and retainer crowns 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 core 
buildup (D2950), a pontic (D6245), and retainer crowns (D6740) for tooth #8, #9, and #10
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on July 12, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. 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 $175 
copayment for Outpatient surgery in an ambulatory surgical center. 
 
You have been asked to pay a $175 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in an ambulatory surgical center 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 surgery provided on July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99215 billed for date of service February 28, 2022. 
 
You asked the Plan to pay for code 99215. You say that the medical records support payment and you believe 
the clinical trial number is located on the HCFA form you completed. The Plan denied your request. The Plan 
says you did not bill with the required clinical triage information on the claim.  The Plan states that it made six 
separate attempts to contact you to get you to provide this information to no avail. 
 
The Plan must follow Medicare rules. Medicare rules say that it is mandatory to report a clinical trial number 
on claims for items/services provided in clinical trials/studies/registries, or under Coverage with Evidence 
Development (CED). Records show that this patient was involved in a trial for a Transcatheter Aortic Valve 
Replacement, but you did not include the required clinical trial number on the claim you submitted.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99215 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99215 billed for date of service February 28, 2022.