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

 
We decided that the Plan has to pay for initial observation care provided on March 21, 2022. 
 
You asked the Plan to pay for the initial observation care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that the provider is out-of-network and authorization was not 
obtained prior to services being rendered. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for initial 
observation care provided on March 21, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2750) and core buildup (D2950) for tooth 
#5 provided on July 12, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to pay more for 
the dental services. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
  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. 
Therefore, we decided that the Plan does not have to pay more for a crown (D2750) and core buildup (D2950) 
for tooth #5 provided on July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the back brace provided on March 08, 
2022. 
 
You asked the Plan to waive the coinsurance for the back brace. You say that you were informed that this 
would be covered without a copayment. 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 prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for the back brace. This item/service falls within the prosthetic 
devices and related supplies benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The allowed amount for the back brace is $1,126.54. The 20% coinsurance applied is 
$225.31. Therefore, we decided that the Plan does not have to waive the coinsurance for the back brace 
provided on March 08, 2022.
Appeal type: Imaging
Decision: Unfavorable

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

 
We decided that the Plan does not have to waive the copayment for office visits provided on June 23, 2022, to 
August 11, 2022. 
 
You asked the Plan to waive the copayment for office visits. 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 $40 
copayment for physician/practitioner services including doctor's office visits. There were 5 visits, resulting in a 
total copayment amount of $200. 
 
You have been asked to pay $40 copayment for each office visit. This item/service falls within the 
physician/practitioner services including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for office visits provided on June 23, 2022, to August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381 x8), 
the gingival irrigation (D4921 x8), 2D oral/facial photographic image (D0350 x2), 3D photographic image 
(D0351), the periodontal scaling and root planing (D4341 x4), the comprehensive oral evaluation (D0150), the 
bitewing x-rays (D0274), the panoramic x-ray (D0330), the first periapical x-ray (D0220), each additional 
periapical x-ray (D0230) provided by an out-of-network provider on August 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the claim was denied because the 
dentist was not in your plan. The Plan denied your request. The Plan says the services are not covered 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 localized delivery of antimicrobial 
agents (D4381 x8), the gingival irrigation (D4921 x8), 2D oral/facial photographic image (D0350 x2), 3D 
photographic image (D0351), and the periodontal scaling and root planing (D4341 x4) are not among those 
covered under this benefit.  
 
Also, the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits.  Therefore, we decided that the Plan does not have to pay for the localized delivery of 
antimicrobial agents (D4381 x8), the gingival irrigation (D4921 x8), 2D oral/facial photographic image (D0350 
x2), 3D photographic image (D0351), the periodontal scaling and root planing (D4341 x4), the comprehensive 
oral evaluation (D0150), the bitewing x-rays (D0274), the panoramic x-ray (D0330), the first periapical x-ray 
(D0220), each additional periapical x-ray (D0230) provided by an out-of-network provider on August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services were rendered at a skilled nursing 
facility. The Plan denied your request. The Plan says no authorization was obtained prior to services provided. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on July 29, 2022, by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-emergency air transport service. 
 
You asked the Plan to pre-approve the non-emergency air transport service. You say that this service is a 
medical necessity. The Plan denied your request. The Plan says the request does not meet Medicare or the 
Health Plan's coverage criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for commercial aircraft 
transport services.  
 
The services you have asked the Plan to pre-approve the non-emergency air transport services. Therefore, we 
decided that the Plan does not have to pre-approve a non-emergency air transport service.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on August 31, 2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you had this done in your providers 
office and should not have a copay. 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 diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for lab services. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for lab services provided on August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics on tooth #29 and 30 (D6245) and retainer 
crowns on tooth #28 and 31 (D6740). 
 
You asked the Plan to pre-approve pontics and crowns. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the documentation fails to indicate any specific need or 
condition that precludes the use of a removable prosthesis. 
 
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 Plan covers pontics and 
crowns when the services are medically necessary and reasonable.  
 
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 pontics and crowns. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that a review of the documentation 
indicates that the crown on tooth #31 is defective. A fixed bridge may be covered if adjacent mandibular anterior teeth are to be replaced and no posterior teeth are missing. In this case, posterior teeth are to be 
replaced (#'s 29 and 30). Also, there are missing mandibular posterior teeth bilaterally. There has been no 
indication that a removable appliance is contraindicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of pontics and crowns have not been met. Therefore, we decided that the Plan does 
not have to pre-approve pontics on tooth #29 and 30 (D6245) and retainer crowns on tooth #28 and 31 
(D6740).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on February 7, 2022. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 64787 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 64787 is implantation of nerve end into bone or muscle 
(List separately in addition to neuroma excision). 
 
We find that CPT code 64787 is not supported in the medical record. Specifically, the code was not billed with 
the required neuroma excision. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64776 is 1.  The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 pay for the surgical services rendered on February 7, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on July 27, 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 $50 
copayment for Emergency care. 
 
You have been asked to pay a $50 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 July 27, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for bloodwork provided on September 8, 2022. 
 
You asked the Plan to waive the copayment for bloodwork. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $10 copayment for bloodwork. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for bloodwork provided on September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on July 27, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab testing provided on July 27, 2022, by an out-
of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for nuclear medicine testing provided on 
August 3, 2022. 
 
You asked the Plan to waive the copayment for nuclear medicine testing. 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $100 copayment for nuclear medicine testing. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for nuclear medicine testing provided on August 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on July 13, 2022, to July 25, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. 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 $188 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $188 copayment for skilled nursing facility (SNF) care. This item/service falls 
within the Skilled nursing facility (SNF) 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. You have been asked to pay a $1,880($188 x 10 days) copayment for your 
SNF stay. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility 
(SNF) care provided on July 13, 2022, to July 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on September 17, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you went to the emergency room 
because your finger was swollen and infected, and you were given an antibiotic. The Plan denied your request. 
The Plan says self-administered drugs are not a covered benefit while under an outpatient hospital stay. 
 
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 
provided on September 17, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on September 02, 2022. 
 
You asked the Plan to pay for the wound care services. You say that a PCP referral is not required for these 
services. 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 wound care services 
provided on September 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on September 
3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for principal care management. You say that the provider had no prior knowledge of 
the patients they will be required to see. The Plan denied your request. The Plan says there was no 
authorization obtained prior to services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for principal care management services provided on 
September 3, 2022, by an out-of-network (OON) provider.