Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99222, 99232) provided on August 8, 2022, to 
August 9, 2022. 
 
You asked the Plan to pay for hospital care. You say that this was billed correctly. The Plan denied your 
request. The Plan says these services should be billed as outpatient services. 
 
The Plan must follow Medicare rules. Medicare rules say that physicians/practitioners who furnish services to a 
hospital outpatient, including in a hospital outpatient department (including in a provider-based department of 
that hospital) or under arrangement to a hospital shall, at a minimum, report the off campus-outpatient hospital 
place-of-service (POS) code 19 or on campus-outpatient hospital POS code 22 irrespective of the setting where 
the patient actually receives the face-to-face encounter. 
 
We looked at the file and Medicare rules. The enrollees claims history shows that she was a hospital outpatient 
at the time the services at issue were provided, but these services were billed with an inpatient POS code, 21. 
Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99222, 99232) provided on August 
8, 2022, to August 9, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on June 3, 
2022, to July 15, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you disagree with the 
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 a $40 
copayment per visit for inpatient stay: covered services/physical therapy.  
 
You have been asked to pay a $40 copayment per visit for physical therapy visits. The amount you are being 
asked to pay is $400 ($40 x 10 visits = $400). This item/service falls within the inpatient stay: covered 
services/physical therapy 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 physical 
therapy visits provided on June 3, 2022, to July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on July 18, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you were given false information because you 
were advised that the hearing aids were not covered. You say the hearing aids should have been covered since 
it is a covered benefit. The Plan denied your request. The Plan says the provider is out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only received in-network.  
 
We looked the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage 
of the hearing aids have not been met. The record shows the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided on July 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 17, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on July 09, 2022. 
 
You asked the Plan to pay for rest home visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for rest home visit provided 
on July 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new/established patient 
(D0150) and full mouth debridement to enable comprehensive oral evaluation and diagnosis on a subsequent 
visit (D4355) provided on September 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had no idea what providers were in- or out-
of-network because the Plan did not provide you with any information. 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. This benefit includes coverage 
for the requested items or services, but only when they are received from an in-network provider. 
 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 comprehensive oral evaluation - new/established patient (D0150) and full mouth debridement to 
enable comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided on September 23, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination and frames. 
 
You asked the Plan to pay for an eye examination and frames. You say that no one stopped to tell you this 
provider is out-of-network with your vision plan. You also say that you never received a booklet, or any 
information like in times past. The Plan denied your request. The Plan says reimbursement request denied for 
services provided by an out of network provider.  
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 services are provided by a contracted provider. 
 
We looked at the file and the Plan's rules. The rules say that vision services must be provided by a contracted 
provider. The record shows that this provider is not in-network. Based on this information, we decided that the 
Plan's rules for coverage of an eye examination and frames have not been met. Therefore, we decided that the 
Plan does not have to pay for an eye examination and frames.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail polymerase chain reaction (PCR) panel provided on 
August 9, 2022. 
 
You asked the Plan to pay for the nail PCR panel. You say that the results of this testing were medically 
necessary to establish the appropriate individualized treatment plan for this enrollee. The Plan denied your 
request. The Plan says the testing is not medically necessary as the requested testing exceeds the enrollee's 
medical needs 
 
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 pay for the nail PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is insufficient scientific evidence in the current medical literature to indicate that this technology is as beneficial as the established alternatives. The nail PCR testing at issue 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 nail PCR panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the nail polymerase chain reaction (PCR) panel provided on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation with limited field 
of view  (D0364), and pulp vitality tests (D0460)  provided on September 27, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and pulp vitality tests. You say that you were told by 
the insurance agent that your Plan covers 50% of services like root canals. You also say that since this was an 
unforeseen emergency the Plan should pay for the 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 cone 
beam CT capture and interpretation with limited field of view  (D0364), and pulp vitality tests (D0460)  
provided on September 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on July 26, 
2022, to July 29, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
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 a $325 
copayment per visit for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per visit for inpatient hospital care. The total amount you are 
being asked to pay $975 ($325 x 3days = $975). This item/service falls within the inpatient hospital care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided 
on July 26, 2022, to July 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that the patient 
tests 4 times per day due to uncontrolled blood sugar. You also say the enrollee has tremors and cannot test 
well due to this. The Plan denied your request. The Plan says the enrollee does not require insulin three or more 
times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your current dentures are broken and 
cannot be repaired. 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 May 24, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular 
partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for individual sterile packet and intermittent urinary catheter 
provided on September 09, 2022. 
 
You asked the Plan to pay for individual sterile packet and intermittent urinary catheter. 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 individual sterile packet 
and intermittent urinary catheter provided on September 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on April 6, 2022. 
 
You asked the Plan to pay for a bone replacement graft. You say that these services were medically necessary. 
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 bone 
replacement graft (D7953) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incisional biopsy of oral tissue-soft (D7286) provided on 
September 8, 2022. 
 
You asked the Plan to pay for the dental service. You say that you had no idea this wasn't covered, and you 
cannot afford it. The Plan denied your request. The Plan says this service is not covered under the Plan's 
supplemental dental 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 an 
incisional biopsy of oral tissue-soft (D7286) provided on September 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on July 11, 2022. 
 
You asked the Plan to pay for dental services. You say that you told the provider not to perform any services 
that are not covered under your plan. 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. Periodontal maintenance 
(D4910) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance (D4910) provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of x-rays provided on September 15, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete series of x-rays provided on September 15, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 04, 2021. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided 
on May 04, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) and a pre-
diagnostic test (D0431) provided on September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to appeal the denied dental 
services. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the comprehensive periodontal evaluation and the pre-diagnostic test are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) and a pre-diagnostic test (D0431) provided on September 27, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug (A9270) provided on  
September 5, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug provided is 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 drug 
(A9270) provided on September 5, 2022.  
 Benefits for this item 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant maintenance (D6080) provided by an out-of-network 
provider on June 14, 2022. 
 
You asked the Plan to pay for the dental service. You say that the Plan should not dictate what providers you 
use. The Plan denied your request. The Plan says the dental service was received from an out-of-network 
provider and is 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 service from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested item or service is 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 implant maintenance (D6080) provided by an out-of-network provider on June 14, 2022.