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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 18, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the original provider never returned your calls 
to complete replacement of your bridgework. You also say that the current provider is in the process of 
replacing the bridgework and the original provider will not be doing any of it. The Plan denied your request. 
The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 19, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a periodic oral evaluation (D0120) and an 
adult prophylaxis (D1110) provided on May 19, 2022. 
 
  You asked the Plan to waive the coinsurance for a periodic oral evaluation (D0120) and an adult prophylaxis 
(D1110). You say that you thought the provider was in-network. You also say that you were told by one of the 
representatives that it would be paid on full. The Plan denied your request. The Plan says this cost sharing was 
charged 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. 
 
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% 
coinsurance for an out-of-network oral examination and cleaning, and for out-of-network x-rays.  
 
You have been asked to pay $14.43, which is 30% of the allowed amount for an adult prophylaxis (D1110) 
($48.12 allowed amount x 30% coinsurance = $14.43). You have also been asked to pay $7.41 in coinsurance, 
which is 30% of the allowed amount for a periodic oral evaluation (D0120) ($24.73 allowed amount x 30% 
coinsurance = $7.41). This item/service falls within the out-of-network x-rays 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 for a periodic oral evaluation (D0120) and an adult prophylaxis 
(D1110) provided on May 19, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing (G0482) provided on September 19, 2022. 
 
You asked the Plan to pay for the drug testing (G0482). You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the drug testing based on Medicare criteria. The Plan's denial reasoning is unclear. Therefore, we 
decided that the Plan has to pay for the drug testing (G0482) provided on September 19, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infusion therapy provided on September 
08, 2022. 
 
You asked the Plan to waive the coinsurance for infusion therapy. You say that you cannot afford to pay the 
coinsurance for these visits. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for infusion therapy. This item/service falls within the Medicare 
Part B prescription drugs 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 for infusion 
therapy provided on September 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) rendered by 
the out-of-network (OON) provider from September 7, 2022, through October 3, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the chiropractic manipulative treatments (98941) rendered by the out-of-network 
(OON) provider from September 7, 2022, through October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on November 10, 
2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you feel like this service was needed. The 
Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 limited 
oral evaluation (D0140) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body (D6010) for tooth 
#30 and tooth #31 provided on August 5, 2022, to August 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service is vital to your oral health and 
quality of life, and you are requesting reconsideration of the denied payments. The Plan denied your request. 
The Plan says the surgical placement of implant body (D6010) is not a covered service. 
 
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 the 
surgical placement of implant body (D6010) for tooth #30 and tooth #31 provided on August 5, 2022, to 
August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 17, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided 
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 an office visit provided 
on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) purchased from an out-of-network 
(OON) provider on October 4, 2022. 
 
You asked the Plan to pay for the frames. You say that you purchased the frames online because the office you 
had your eyes examined at was double the price, less quality, and customer service was bad. You also say that 
you would like to be reimbursed because you need the money. The Plan denied your request. The Plan says 
these frames were provided by a provider that is not in the Plan's network. The Plan also says there are network 
providers available to perform the services at issue in this appeal. 
 
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 these services when they are purchased from an in-network provider. 
 
We looked at the file and the Plan's rules. Specifically, you purchased these frames from an online retailer that 
is not in the Plan's network. Based on this information, we decided that the Plan's rules for coverage of the 
frames have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020) 
purchased from an out-of-network (OON) provider on October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 14, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided 
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 an office visit provided 
on September 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Yervoy (Ipilimumab). 
 
You asked the Plan to pre-approve Yervoy (Ipilimumab). You say that the requested Yervoy (Ipilimumab) is 
medically necessary. The Plan denied your request. The Plan says the requested Yervoy (Ipilimumab) is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Yervoy (Ipilimumab). Our reviewer 
says that the requested Yervoy (Ipilimumab) is not medically necessary. Our physician reviewer found the 
record indicates that the enrollee has a diagnosis of B cell lymphoma and epithelioid angiosarcoma. The Food 
and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted 
for review. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Yervoy (Ipilimumab) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Yervoy (Ipilimumab).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on September 24, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the services were provided in good faith 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 genetic testing provided 
on September 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for speech therapy services provided on 
November 01, 2022. 
 
You asked the Plan to waive the copayment for speech therapy services. You say that you should not pay for 
services when they are not clearly defined and you have no confidence in the Plans billing systems. 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 $10 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $10 copayment for speech therapy services. This item/service falls within the 
outpatient rehabilitation service benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
speech therapy services provided on November 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on September 02, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the records attached support the services provided 
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 genetic testing provided 
on September 02, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on September 5, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had 
COVID-19, and your husband contacted the Emergency Medical Services (EMS) because he was very worried 
since you were so sick. You also say since you live in a rural area, the EMS was the best option for medical 
attention. The Plan denied your request. The Plan says you were seen by the EMS because you had COVID-19 
and were very sick. The Plan also says that you were not transported anywhere. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 5, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on September 5, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services (97535, 97110, 97530) 
provided on June 4, 2022, to June 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. You say that a new authorization should have been submitted. 
The Plan denied your request. The Plan says these services are not covered when provided OON. 
 
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 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 the physical therapy (PT) services (97535, 97110, 
97530) provided on June 4, 2022, to June 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the methadone treatment (G2067) provided on September 26, 
2022. 
 
You asked the Plan to pay for the methadone treatment. 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 billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. The rules also say that only an entity enrolled with 
Medicare as an OTP can bill these codes. 
 
We looked at the file and Medicare rules. The claim was billed by the rendering provider and not an OTP 
facility. Individual providers cannot bill for OTP services. Based on this information, we decided that Medicare rules for coverage of the methadone treatment have not been met. Therefore, we decided that the Plan does not 
have to pay for the methadone treatment (G2067) provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management provided on May 31, 2022. 
 
You asked the Plan to pay for chronic care management. 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 chronic care 
management provided on May 31, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient admission provided on January 10, 2022. 
 
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says that this 
stay is denied. The Plan also says you may resubmit this claim under Part B. 
 
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 records do not support that this stay should be denied. This means that the 
Plan has not provided a valid reason for denying payment of the inpatient admission. It is the burden of the 
Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we 
must find in your favor. Therefore, we decided that the Plan has to pay for the inpatient admission provided on 
January 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.