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

 
We decided that the Plan does not have to waive the copayment for periodontal scaling and root planning 
(D4341) provided by an out-of-network provider on July 8, 2021. 
 
You asked the Plan to waive the copayment for periodontal scaling and root planning. You say that you do not 
understand why you are being charged again. 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 $60 
copayment for dental advantage.  
 
You have been asked to pay a $60 copayment for each periodontal scaling and root planning. Two D4341 were 
provided on the date of service in question; therefore, the total amount you are being asked to pay is $120 ($60 
+ $60 = $120). This item/service falls within the dental advantage 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 periodontal scaling and root planning (D4341) provided by an out-of-network 
provider on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite of three surfaces (D2393) 
provided on June 7, 2022. 
 
You asked the Plan to pay for the resin-based composite. You say that you were not aware that there was a 
limitation of only two covered fillings per year. 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 June 7, 2022. Therefore, 
we decided that the Plan does not have to pay for the resin-based composite of three surfaces (D2393) provided 
on June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on June 20, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you should be getting a free yearly 
visit and not be charged 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 a $15 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for office visit. This item/service falls within the 
Physician/Practitioner services, including doctors 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 visit provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on June 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you were told prior to receiving these 
services that all maintenance care would be covered, and you thought the treating provider was in-network. 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. The Plan also says that you 
did not contact the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 OON 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 the periodic oral evaluation (D0120), bitewing x-rays (D0274), and 
prophylaxis (D1110) provided on June 28, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and injection provided on February 18, 2022, 
by an OON provider. 
 
You asked the Plan to pay for an office visit and injection. The Plan denied your request. The Plan says the out-
of-network services were not authorized. 
 
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 an office visit and injection provided on February 
18, 2022, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography services (procedure code 75710) provided to the 
enrollee on March 15, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the requested code cannot be verified. 
 
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 75710 is "Angiography, extremity, unilateral, 
radiological supervision and interpretation." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the paid CPT 37228 would 
require angiographic analysis both before and after the revascularization procedure. As such, the denied CPT 
75710 was denied appropriately as the angiography would be considered a customary part of the paid 
procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for angiography services (procedure code 75710) provided to the enrollee on March 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided to the 
enrollee on March 5, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance was called 
by urgent care without notification. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 copayment for one-way ambulance services.  
 
The enrollee has been asked to pay a $325 copayment for the ambulance services. This item/service falls within 
the one-way ambulance services benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for ambulance services provided to the enrollee on March 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on 
September 13, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for these services. 
The Plan denied your request. The Plan says the rendered dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until November 30, 2023. Therefore, we decided that the Plan does not 
have to pay for dental services provided by an opt-out provider on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 1, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that you only had coverage 
for one comprehensive oral evaluation every three years. 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 October 12, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on July 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient visit provided on May 25, 2022. 
 
You asked the Plan to waive the coinsurance for outpatient visit. You say that you pay a monthly premium for 
insurance and you are puzzled why you received this bill. 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% 
coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay 10% coinsurance for outpatient visit. This item/service falls within the outpatient 
surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 
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 is $25,968.58, you pay 10% equals $2,596.86 which is your coinsurance amount. Therefore, 
we decided that the Plan does not have to waive the coinsurance for outpatient visit provided on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a periapical x-ray provided on May 19, 2022. 
 
You asked the Plan to pay for an x-ray. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says that your benefit for the requested item or service has already been 
exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. The Plan did not provide documentation showing what type of x-rays were received on 
January 3, 2022. Without that information we are unable to determine if your benefit for periapical x-rays has 
been exhausted. Therefore, we decided that the Plan has to pay for a periapical x-ray provided on May 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5225) provided on June 22, 
2022. 
 
You asked the Plan to pay for the denture. You say that you feel the plan should pay for some of the amount 
that is due. You say that you had a lot of teeth pulled and you needed the denture. The Plan denied your 
request. The Plan says the 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 
maxillary partial denture (D5225) provided on June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment on April 05, 2022, to 
May 05, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you feel the urologist should 
pay this bill. 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 18% 
coinsurance for durable medical equipment provider. Covered items include, but are not limited to wheelchairs, 
crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use in the home, 
IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, and walkers. The provider billed 
in the amount of $474 and the plan discount is $379.08. $474 - $379.08 = $94.92 x 18% = $17.08. There were 
two dates of service. $17.08 x 2 = $34.16. Therefore, results in the total cost sharing amount of $34.16. 
 
 
 
 You have been asked to pay a 18% coinsurance for oxygen equipment. This item/service falls within the 
Durable medical equipment (DME) 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. Therefore, we decided that the Plan does not have to waive 
the coinsurance for oxygen equipment on April 05, 2022, to May 05, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 28, 2022. 
 
You asked the Plan to waive the copayment for diagnostic radiology. You say that you do not understand why 
you have to pay that much out of pocket. 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 $275 
copayment for Medicare-covered diagnostic radiology service.  
 
You have been asked to pay $184.86, which is less than the $275 copayment for diagnostic radiology. This 
item/service falls within the Medicare-covered diagnostic radiology 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 a computed tomography (CT) scan provided on March 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ViviGen Allograft (20930) for a spinal surgery. 
 
You asked the Plan to pre-approve a ViviGen Allograft. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
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 a ViviGen Allograft. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is limited published, large-scale, long-term, peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the enrollee's pathology. Further studies are needed to 
demonstrate the requested allograft is superior to the standard allografts. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ViviGen Allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ViviGen Allograft (20930) for a spinal surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee presented with decreased balance, 
decreased strength and fatigue which impedes ADLs and functional mobility. They would benefit from 
continued skilled OT services to improve ADLs, functional mobility, and functional transfers. The Plan denied 
your request. The Plan says this is not medically necessary. The enrollee can safely receive the services they 
needs in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422) 
provided on April 6, 2022. 
 
You asked the Plan to pay for the ambulance oxygen and oxygen supplies. You say that you would like this 
claim to be reprocessed for payment. The Plan denied your request. The Plan says the denial of the oxygen and 
oxygen supplies was appropriate given the clinical scenario and guidance presented. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, 
is included in the fee schedule payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance oxygen and oxygen supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance oxygen and oxygen supplies (A0422) provided on April 6, 2022.