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

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
November 14, 2021, to December 2, 2021. 
 
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 $295 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $295 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay is $1,475 ($295 x 5 days = $1,475). 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 November 14, 2021, to December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, 
including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested procedure is medically 
necessary and supported by strong science. The Plan denied your request. The Plan says unproven and not 
medically necessary procedures are not covered by Medicare. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental and investigational. There is more info 
needed due to insufficient evidence of efficacy. 
 
 
 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve, including all imaging 
guidance; first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skin growth removal provided on 
November 8, 2022. 
 
You asked the Plan to waive the copayment for the skin growth removal. You say that you were charged two 
copayments. 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 $25 
copayment for each surgical service provided in a specialist's office.  
 
The records show that you were only charged a single copayment for $25. You have been asked to pay a $25 
copayment for the skin growth removal. This item/service falls within physician/practitioner services 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 skin growth removal provided on November 
8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to waive the copayment for an ambulance transport service provided on 
July 25, 2022. 
 
You asked the Plan to waive the copayment for an ambulance transport. You say that the ambulance took the 
enrollee to the wrong hospital, and the enrollee should not have to pay. 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 ambulance services.  
 
The enrollee has been asked to pay a $325 copayment for an ambulance transport. This item/service falls 
within the 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 
an ambulance transport service provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous moderate sedation services (D9239, D9243) 
provided on December 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
intravenous moderate sedation services (D9239, D9243) provided on December 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an magnetic resonance imaging (MRI) 
provided on August 12, 2022. 
 
You asked the Plan to waive the copayment for an magnetic resonance imaging (MRI). You say that you 
disagree with the copaymet. 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 $210 
copayment for outpatient diagnostic tests/MRI. 
 
You have been asked to pay a $210 copayment for an magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests/MRI 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 an magnetic resonance imaging (MRI) provided on August 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on September 22, 2022. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says your provider has attested that you do not meet all three 
of the criteria. Therefore, you do not qualify for services under SSBCI program. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not meet the 
intensive care management criteria listed in the EOC, which is 2 or more inpatient admission in the last 60 
days, or 3 or more emergency room visits in the last 60 days. Therefore, we decided that the Plan does not have 
to pre-approve the SSBCI benefits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelegy Ellipta (J3535). 
 
You asked the Plan to pre-approve Trelegy Ellipta. You say that the enrollee has chronic obstructive pulmonary 
disease and emphysema. The Plan denied your request. The Plan says Trelegy Ellipta is a self-administered 
drug, and does not fall under Part B coverage. 
 
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 pre-approve Trelegy Ellipta (J3535).  
 
  Benefits for Trelegy Ellipta 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 pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve the occlusal guard. You say that you need the guard to stop you from 
grinding your teeth. The Plan denied your request. The Plan says we made multiple attempts to get the x-rays 
and a narrative from your dentist's office but we did not receive them. Therefore, we cannot make a decision on 
medical necessity. 
 
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, there is insufficient information to 
determine if Medicare rules for coverage have been met. It has not been shown that the Plan should cover your 
request due to the missing medical records. If you still would like coverage, you or the provider should submit 
a new request to the Plan with supporting records. Therefore, we decided that the Plan does not have to pre-
approve an occlusal guard  hard appliance, full arch (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 18, 
2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a domiciliary or rest 
home visit provided on October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you should meet the criteria for chronically 
ill. The Plan denied your request. The Plan says there is no documentation that the enrollee meets criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 08, 2022, to August 
05, 2022. 
 
You asked the Plan to pay for home health services. 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 home health services 
provided on July 08, 2022, to August 05, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional inpatient psychiatric services. 
 
You asked the Plan to pre-approve additional inpatient psychiatric services. You say that the enrollee needs this 
level of care. The Plan denied your request. The Plan says Medicare does not cover more than 190 days of 
inpatient psychiatric care during an enrollee's lifetime. This limit has previously been reached. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a lifetime maximum of 190 days on 
inpatient psychiatric hospital services available to any beneficiary. 
 
We looked at the file and Medicare rules. Review of the file shows that as of March 7, 2023, all 190 inpatient 
psychiatric days have been used. Based on this information, we decided that Medicare rules for coverage of 
additional inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided from November 2, 2022, to 
November 15, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that you need the equipment that you were given 
for your problem. You say that you paid out-of-pocket for all of this. You say that you should be reimbursed 
for this. You also say that you have noticed improvement since using this equipment. The Plan denied your 
request. The Plan says chiropractic services other than manual manipulation for subluxation are not covered. 
 
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 outpatient services provided from November 2, 2022, to November 15, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests and a specialist 
office visit provided on February 14, 2022, to April 26, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests and a specialist office visit. 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 $150 
copayment per visit for outpatient diagnostic tests/Medicare-covered diagnostic procedures and tests and a $20 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $150 copayment per visit for outpatient diagnostic tests/Medicare-covered 
diagnostic procedures and tests and a $20 copayment for physician/practitioner services/specialist. The total amount you are being asked to pay for the outpatient diagnostic test is $300 ($150 x 2 visits = $300).The total 
amount you are being asked to pay for all services is $320 ($300 + $20 = $320). This item/service falls within 
the outpatient diagnostic tests/Medicare-covered diagnostic procedures and tests and physician/practitioner 
services/specialist 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 outpatient diagnostic 
tests and a specialist office visit provided on February 14, 2022, to April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
November 8, 2022. 
 
You asked the Plan to pay for the dental service. You say that you thought the dentist you were referred to by 
the Plan was in-network. 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 April 6, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a wound debridement and an ultrasound 
provided on August 19, 2021. 
 
You asked the Plan to waive the copayments for the wound care services and the ultrasound. You say that you 
wanted these services from your primary care provider. 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 $335 
copayment for Medicare-covered surgery provided at an outpatient hospital. Your contract also clearly says 
that you must pay a $110 copayment for Medicare-covered radiological diagnostic services, including an 
ultrasound. 
 You have been asked to pay $223.20, which is less than the standard $335 copayment for the wound 
debridement. This item/service falls within the outpatient surgery benefit category. You have also been asked 
to pay a $110 copayment for the ultrasound. This item/service falls within the outpatient diagnostic tests and 
therapeutic services benefit category. You have been asked to pay a total of $333.20 ($223.20 copayment + 
$110 copayment = $333.20). 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 copayments for a wound debridement and 
an ultrasound provided on August 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 6, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
unaware that the ambulance would not be covered since you were not transported. You also say that you feel 
the claim should be covered as you  had fallen and could not get back up. The Plan denied your request. The 
Plan says these services are not a covered benefit. 
 
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 November 6, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 6, 2022.