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

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery services (47562) and 
pay for the self-administered drugs (A9270), provided on October 19, 2022. 
 
You asked the Plan to waive the copayment for the outpatient surgery services and pay for the self-
administered drugs. You say that the services should be covered. The Plan denied your request. The Plan says 
self-administered drugs are not covered and the cost share for surgery was applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270), provided on October 19, 2022. You have been asked to pay $345 for the outpatient surgery services. 
This item falls within the outpatient hospital 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 
copayment for the outpatient surgery services (47562), provided on October 19, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on September 8, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was not on hospice at the time of 
service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on September 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluorscopic evaluation of swallowing function (92611), 
imaging for evaluation of swallowing function (74230), and radiological examination (x-ray) of upper digestive 
tract (74240), provided on September 2, 2022. 
 
You asked the Plan to pay for the portable x-ray services. You say that these services should be covered. The 
Plan denied your request. The Plan says portable x-ray services are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures and examinations which are not 
covered under the portable x-ray provision include the following: 
 Procedures involving fluoroscopy; 
 Procedures involving the use of contrast media; 
 Procedures requiring the administration of a substance to the patient or injection of a substance into the 
patient and/or special manipulation of the patient; 
 Procedures which require special medical skill or knowledge possessed by a doctor of medicine or doctor of 
osteopathy or which require that medical judgment be exercised; 
 Procedures requiring special technical competency and/or special equipment or materials; 
 Routine screening procedures; and 
 Procedures which are not of a diagnostic nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the portable x-ray services have not been met. Therefore, we decided that the Plan does not have to 
pay for the fluorscopic evaluation of swallowing function (92611), imaging for evaluation of swallowing 
function (74230), and radiological examination (x-ray) of upper digestive tract (74240), provided on September 
2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiological examination (x-ray) of the swallowing 
function (74230), and gastrointestinal tract x-ray (74240), provided on October 13, 2022. 
 
You asked the Plan to pay for the portable x-ray services. You say that the services should be covered. The 
Plan denied your request. The Plan says these are not covered services. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures and examinations which are not 
covered under the portable x-ray provision include the following: 
 Procedures involving fluoroscopy; 
 Procedures involving the use of contrast media; 
 Procedures requiring the administration of a substance to the patient or injection 
of a substance into the patient and/or special manipulation of the patient; 
 Procedures which require special medical skill or knowledge possessed by a 
doctor of medicine or doctor of osteopathy or which require that medical 
judgment be exercised; 
 Procedures requiring special technical competency and/or special equipment or 
materials; 
 Routine screening procedures; and 
 Procedures which are not of a diagnostic nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the portable x-ray services have not been met. Therefore, we decided that the Plan does not have to 
pay for the radiological examination (x-ray) of the swallowing function (74230), and gastrointestinal tract x-ray 
(74240), provided on October 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits due to recent hospitalizations. The Plan denied your request. The Plan says you do not meet the criteria 
to be eligible for SSBCI benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not meet the 
intensive care management criteria listed in the EOC, which is 2 or more inpatient admission in the last 60 
days, or 3 or more emergency room visits in the last 60 days. Therefore, we decided that the Plan does not have 
to pre-approve the SSBCI benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts. 
 
You asked the Plan to pre-approve diabetic shoes and inserts. You say that due to the loss of sensibility this 
puts you at a high risk of injury, infection, or another related situation. The Plan denied your request. The Plan 
says we don't have evidence that the coverage criteria were met. The Plan attempted to contact the physician 
who requested these services to obtain clinical information to evaluate your request. The Plan also says after 
multiple attempts to contact you, or contact was made, the requested information was not obtained or provided. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of diabetic shoes and inserts have been 
met. There were no medical records provided. Without this  necessary information we are unable to determine 
whether criteria for coverage have been met and whether approval is medically necessary. The Plan has shown that they mad reasonable attempts to obtain the necessary information. Therefore, we decided that the Plan 
does not have to pre-approve diabetic shoes and inserts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit provided on September 14, 
2022. 
 
You asked the Plan to waive the cost share for an office visit. You say that you disagree with the cost share. 
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. Your 
contract with the Plan says that there is a 2% coinsurance and a $400 deductible which applies to 
physician/practitioner services.  
 
The item or service you asked the Plan to waive the cost share for falls within the physician/practitioner 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a 2% coinsurance and a $400 deductible which applies to physician/practitioner services. You are being 
asked to pay $181.72 towards your $400 deductible. Also, a $.47 towards your coinsurance. The total amount 
you are being asked to pay is $181.89 ($181.72 + $.47 = $181.89). This cost sharing is a contractual obligation 
that had not been met at the time an office visit was received on September 14, 2022. Therefore, we decided 
that the Plan does not have to waive the cost share for an office visit provided on September 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ultrasound provided on October 19, 
2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that you disagree with the copayment 
amount. 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 in-network Medicare-covered radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay $141.76, which is less than the standard $175 copayment for the ultrasound. This 
item/service falls within the outpatient diagnostic tests and therapeutic 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 reduce the copayment for the ultrasound provided on October 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from September 11, 2022, to October 10, 
2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer required 
skilled nursing facility needs. 
 
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 did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a 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 SNF care provided from September 11, 2022, to October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA genetic testing. 
 
You asked the Plan to pre-approve BRCA tests. You say that you have a family member with cancer. The Plan 
denied your request. The Plan says BRCA screening in an enrollee without a personal history of cancer is not 
medically necessary. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The tests at issue in this appeal, BRCA tests, are being requested solely for screening purposes. Medicare does 
not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pre-
approve BRCA genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), the 2D 
photographic images (D0350), an extraction (D7210), and a consultation (D9310) for tooth #31 provided by an 
out-of-network provider on November 10, 2022, and November 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that the provider was in-network, 
and the dental services would be covered. The Plan denied your request. The Plan says your benefit for the 
panoramic radiographic image has already been exhausted and you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. Also, 
the denial of payment for the 2D photographic images, extraction, and a consultation is correct, because they 
are not covered by the Plan. The Plan also verified there were no calls made from the enrollee or the provider 
to the Plan to verify 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. You have 
been asked to pay the difference between the out-of-network providers charges and the Plans payment. This 
cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The record shows the 
Plan paid for an intraoral radiographic image (D0210) on November 10, 2022; therefore, your benefit for the 
panoramic radiographic image was exhausted on date of service November 10, 2022. The 2D photographic 
images, extraction, and the consultation are not covered under the Plans dental benefit. Therefore, we decided 
that the Plan does not have to pay for the panoramic radiographic image (D0330), the 2D photographic images 
(D0350), an extraction (D7210), and a consultation (D9310) for tooth #31 provided by an out-of-network 
provider on November 10, 2022, and November 16, 2022.  
 
Your complaint about a sales representative is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, incl elevation of mucoperiosteal flap (D7210). 
 
You asked the Plan to pre-approve dental services. You say that you see that a simple extraction is covered 
under your plan, so you thought that was what the procedure was being billed as. You say that you did not 
realize the provider billed the procedure as oral surgery. 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. Extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth, incl elevation of mucoperiosteal flap (D7210) is not 
covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7210 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth, incl elevation of mucoperiosteal flap 
(D7210).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting to be admitted back to the skilled 
nursing facility you were previous, you have one hand and need assistance. The Plan denied your request. The 
Plan says that you do not meet the criteria for a skilled nursing admission. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that you had acute clinical and functional status change 
thus would require assessment by skilled nursing and therapy. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a problem focused exam (D0140), and a pulp vitality test 
(D0460), provided on October 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that this provider was in-network. 
The Plan denied your request. The Plan says these services have been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 D0140 was exhausted on date of service October 22, 2022. D0460 is not a covered 
dental benefit. Therefore, we decided that the Plan does not have to pay for a problem focused exam (D0140), 
and a pulp vitality test (D0460), provided on October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgeries provided on July 29, 
2022, to December 30, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgeries. You say that you disagree with the 
copayments. 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 $295 
copayment per visit for outpatient surgery.  
 
You have been asked to pay a $295 copayment per visit for outpatient surgeries. The total amount you are 
being asked to pay $2,655 ($295 x 9 visits = $2,655). This item/service falls within the outpatient surgery 
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 surgeries provided on 
July 29, 2022, to December 30, 2022.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 We decided that the Plan has to waive one $40 copayment for occupational therapy services. We decided that 
the Plan does not have to waive the coinsurance for DME and the remaining $40 copayment.  
 
You asked the Plan to waive the cost for occupational therapy services and DME provided on November 18, 
2022. You say that you already paid $40 and are frustrated about the additional charges. The Plan says that this 
cost sharing was charged correctly. 
 
We decided that the Plan has to waive one $40 copayment for the occupational therapy services.  
 
The Plan says you must pay a $40 copayment for the occupational therapy evaluation and a $40 copayment for 
an occupational therapy treatment. The Evidence of Coverage states a $40 copayment is charged for outpatient 
rehabilitation visits. The occupational therapy evaluation and occupational therapy treatment were provided 
during the same visit and billed by the same provider. This means that two separate copayments should not 
apply. Therefore, we decided that the Plan has to waive one $40 copayment for the occupational therapy 
services.  
 
We also decided that the Plan does not have to waive the coinsurance for DME and the remaining $40 
copayment. 
 
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 Medicare-covered physical, occupational, and speech therapy visits and 20% coinsurance for 
DME. Therefore, we decided that the Plan does not have to waive the remaining $40 copayment for the 
occupational therapy services and 20% coinsurance for DME. 
 
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.