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

 
We decided that the Plan has to pay for inpatient hospital care provided on March 30, 2022. 
 
You asked the Plan to pay for inpatient hospital care. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that this is service was not authorized. 
 
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. Specifically, the Plan has not provided a Medicare rule or a Plan rule to 
substantiate the denial. Therefore, we decided that the Plan has to pay for inpatient hospital care provided on 
March 30, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that the records provided support the need for the 
Intracept procedure. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there were/are multiple plausible pathologic sources of significant pain generation. The 
aching and constant back pain, the noted pain-aggravating factors (walking), pain-relieving factors (sitting and 
not moving), along with the intact neurologic exam were/are all non-specific to any pathologic entities. 
Overall, documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of 
the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain. Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as 
being medically necessary and/or reasonable at this time. Overall, there is a lack of compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested Intracept intraosseous basivertebral nerve ablation at L3, L4, L5, and S1, in this case, 
is not medically reasonable or necessary. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth or exposed root (D7140) 
provided on July 29, 2022. 
 
You asked the Plan to pay for the extraction (D7140). You say that the medical records provided support the 
need for the extraction. The Plan denied your request. The Plan says this service is not covered under the 
benefit package. 
 
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 an 
extraction, erupted tooth or exposed root (D7140) provided on July 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on October 17, 2022. 
 
You asked the Plan to pay for wound care supplies. 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 wound care supplies 
provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic tooth #29 (D2740), and core 
buildup, including any pins when required tooth #29 (D2950) provided on August 9, 2022. 
 
You asked the Plan to pay for codes D2740 and D2950. You say that the 2022 policy enrollment guide states 
50% for covered comprehensive dental services. The Plan denied your request. The Plan says these services are 
not covered under the benefit package.  
 
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 crown - 
porcelain/ceramic tooth #29 (D2740), and core buildup, including any pins when required tooth #29 (D2950) 
provided on August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on August 30, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON evaluation and management services. You say that the medical records 
provided support the need for the services in dispute. The Plan denied your request. The Plan says the services 
provided out-of-network were not pre-authorized. The Plan says that there was no network deficiency for the 
services in dispute, and alternate network providers were available. 
 
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 
OON service at issue. We found no exception that would require the Plan to pay for these OON services. 
Therefore, we decided that the Plan does not have to pay for evaluation and management services provided on 
August 30, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network chemotherapy drugs and 
administration provided on June 30, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that the Plan should be covering 
more than they are for this service. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a $780.24 coinsurance for chemotherapy drugs ($14,034.24 allowed amount x 
20% = $2806.85). The Plan is holding you responsible for less than 20% coinsurance. 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 out-of-network chemotherapy drugs and administration provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician (D9310), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) 
provided on November 16, 2022. 
 
You asked the Plan to pay for codes D9310 and D7210. You say that you were advised by the Plan that 
consultations were not covered. You also say that you paid for the consultation and extraction even though you 
were told they were covered under your plan. The Plan denied your request. The Plan says the consultation is 
not covered under the benefit package. 
 
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 consultation - diagnostic service 
provided by dentist or physician (D9310) is not among those covered under this benefit.  
 Therefore, we decided that the Plan does not have to pay for a consultation - diagnostic service provided by 
dentist or physician (D9310). The dental office has confirmed that you were reimbursed for the extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on November 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment provided on October 15, 
2022. 
 
You asked the Plan to pay for ambulance response and treatment. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the enrollee was not actually transported by 
ambulance; this expense is not covered by the member's benefit plan. 
 
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 October 15, 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 ambulance response and treatment provided on 
October 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation  per quadrant (D4921) and drugs or 
medicaments dispensed in the office for home use (D9630) provided on November 14, 2022. 
 
You asked the Plan to pre-approve dental services. You say that you were not aware of any out-of-pocket cost; 
therefore, you should not have to pay for the billed services. The Plan denied your request. The Plan says these 
services are 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. Gingival irrigation  per 
quadrant (D4921) and drugs or medicaments dispensed in the office for home use (D9630) 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 pre-approve 
gingival irrigation  per quadrant (D4921) and drugs or medicaments dispensed in the office for home use 
(D9630) provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for one intraoral image. We decided that the Plan does not have to pay for 
the additional intraoral images, or for periodontal scaling and root planing.  
 
You asked the Plan to pay for additional intraoral imaging (D0230), and periodontal scaling and root planing 
(D4341), provided on October 26, 2022, to November 11, 2022. You say that you would like the Plan to pay 
for this. The Plan says that these services have been correctly denied. 
 
 We decided that the Plan has to pay for one intraoral image.  
 
One intraoral image is covered every calendar year. Therefore, we decided that the Plan has to pay for one 
intraoral image.  
 
We also decided that the Plan does not have to pay for additional intraoral images periodontal scaling 
and root planning. 
 
periodontal scaling and root planning is not a covered benefit, and additional intraoral imaging have been 
correctly denied. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root 
planning or additional intraoral imaging. 
 
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 endodontic therapy (D3330), and a limited oral evaluation 
(D0140), provided on December 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware you had to stay within 
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for endodontic therapy (D3330), and a limited oral evaluation (D0140), provided on December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 25, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for the physician's services. You say that this doctors office took your medical 
history and gave you a flu shot and made appointments for follow up tests. The Plan denied your request. The 
Plan says when you become a member of our Plan, you must choose a Plan provider to be your primary care 
physician. The services were performed by non-participating provider. 
 
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 
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 physician's services provided on October 25, 2022, by an out-of-
network provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for injection and intravenous infusion chemotherapy and other highly 
complex drug or highly complex biologic agent administration (code 96413) provided on May 27, 2022. 
 
You asked the Plan to pay for injection and intravenous infusion chemotherapy and other highly complex drug 
or highly complex biologic agent administration. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that the member's plan excludes coverage for charges for, or in connection 
with, services or supplies that we determine to be experimental, investigational, cosmetic, or not generally 
recognized according to professional standards of safety and effectiveness in the United States for diagnosis, 
care, or treatment. 
 
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. Specifically, the Plan has not provided a Medicare rule or a Plan rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for injection and intravenous infusion 
chemotherapy and other highly complex drug or highly complex biologic agent administration (code 96413) 
provided on May 27, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on June 15, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on June 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 14, 2022, to 
March 22, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says that documentation 
does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code N17.9, described as acute 
kidney failure, unspecified. We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that documentation does not support the billed 
code. Our physician reviewer found there was no clinical or laboratory evidence of acute tubular necrosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 14, 2022, to March 22, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation services (A0428, A0425) provided on June 
17, 2022. 
 
You asked the Plan to pay for ambulance services. You say that this transportation was provided when the 
enrollee was discharged from one facility and transferred to another for a separate admission; therefore, these 
services are paid separately. The Plan denied your request. The Plan says that the payment for these services is 
included in the original payment already made to the facility. 
 
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 rules say that if an enrollee is transferred between two facilities and the provider numbers of 
these facilities/providers are different, then the ambulance services are separately billable to the program. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the documentation provided includes a claims screen which shows 
that a different claim was submitted by a different facility for the dates immediately following this 
transportation, and the case narrative indicates that this transportation was provided for a facility transfer. There 
is no evidence to support that the enrollee was transferred from one provider facility to another run by the same 
provider, but rather was transferred to a different provider and facility. This means that this transport is 
separately payable under Part B. Therefore, we decided that the Plan has to pay for ambulance transportation 
services (A0428, A0425) provided on June 17, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
February 1, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says a 
corrected claim must be receive within one year (12 months) from the processed date of the original claim 
submission. 
 
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 emergency department visit was not filed until September 8, 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 an emergency department visit provided on 
February 1, 2021.