Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 8, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you would like an explanation why 
this bill was originally denied but now received a bill for $74.20. The Plan denied your request. The Plan says 
you have been charged the correct copayment amount. 
 
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 $160 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or free-standing facility.  
 
 
 
 You have been asked to pay $74.20, which is less than the standard $160 copayment for the ultrasound. The 
ultrasound falls within the Medicare-covered Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided on 
November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99152) provided on October 14, 2021. 
 
You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied 
your request. The Plan says this is not documented. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not document 
the presence of an independent trained observer. Based on this information, we decided that Medicare rules for 
coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
sedation services (99152) provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim implant crowns (D6085). 
 
You asked the Plan to pre-approve interim implant crowns. You say that this service is necessary. The Plan 
denied your request. The Plan says this service is not covered under the enrollee's 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 pre-approve 
interim implant crowns (D6085).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office or other outpatient visit provided on 
April 30, 2021. 
 
You asked the Plan to pay for a new patient office or other outpatient visit. The Plan denied your request. The 
Plan says this service is not covered by the Plan under any circumstance. 
 
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 a new patient office or other outpatient visit provided on April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two custom abutments (D6057 x2) and two abutment 
supported porcelain/ceramic crowns (D6058 x2) provided on January 7, 2022. 
 
You asked the Plan to pay for the custom abutments and abutment supported porcelain/ceramic crowns. You 
say that the Plan honored a claim for a similar procedure in 2021, and you believe the same claim, or a similar 
claim should be honored by the Plan in 2022. You also say that you would like these services to be covered at a 
50% coinsurance. The Plan denied your request. The Plan says these services are not covered. The Plan also 
says that you signed a pay agreement with the provider verifying that you agreed to be responsible for all of the 
services rendered on your behalf. 
 
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 two 
custom abutments (D6057 x2) and two abutment supported porcelain/ceramic crowns (D6058 x2) provided on 
January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on June 9, 2021, and October 
4, 2021, by an OON provider. 
 
You asked the Plan to pay for the physician services. You say that it was medically necessary to treat the 
enrollee and you would like the claim reviewed. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 the physician services provided on June 9, 2021, 
and October 4, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Ankle Gauntlet provided on February 16, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Ankle Gauntlet. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 Ankle Gauntlet provided on February 16, 2022 by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from November 18, 2021, to December 17, 2021.

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 there is no daily skilled nursing or therapist need.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from November 18, 2021, to December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Injections provided on December 29, 2021. 
 
You asked the Plan to waive the copayment for Injections. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says the coinsurance applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Injections. The allowed amount of the injection is $1,271.40, resulting in a coinsurance amount 
of $254.28. 
 
You have been asked to pay 20% coinsurance for Injections. Injections fall 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 copayment for Injections provided 
on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 22, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that instead of being processed 
as a specialist office visit with a $25 copayment, it should have been processed as an outpatient vision care 
physician service. The Plan denied your request. The Plan says you were charged the correct cost sharing 
amount. 
 
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 Medicare-covered specialist visit for physician/practitioner services, including doctors 
office visits.  
 
You have been asked to pay a $25 copayment for a specialist office visit. A specialist office visit 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 a specialist office visit provided on December 22, 2021.  
 
Your complaint about the provider potentially labeling this incorrectly is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve a complete upper denture. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded 
the frequency limit of one every 5 years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a complete upper denture have not been met. Specifically, the record shows that you had exceeded 
the frequency limit for this service on February 22, 2021. Therefore, we decided that the Plan does not have to 
pre-approve a complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on November 26, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the home health visit. You say that the facility is responsible to get the 
authorization and it was medically necessary to treat the enrollee. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 a home health visit provided on November 26, 
2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Drug Testing provided on December 15, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Drug Testing. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 Drug Testing provided on December 15, 2021 by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for and office visit and an x-ray of the knee provided on August 
17, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for and office visit and an x-ray of the knee. You say that authorization is not 
required for office visits and x-rays. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan, and they have also determined that these services are not urgent or emergent, nor were 
they approved in advance. 
 
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 and office visit and an x-ray of the knee provided 
on August 17, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that the requested seat lift mechanism is 
medically necessary. The Plan denied your request. The Plan says that you do not meet criteria. 
 
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, it is the plans responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plans 
failure to obtain records that are within the plans control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the seat lift mechanism. Therefore, we decided 
that the Plan has to pre-approve a seat lift mechanism.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TERT (telomerase reverse transcriptase) laboratory 
services (81345-GZ) provided on August 11, 2021. 
 
You asked the Plan to pay for code 81345-GZ. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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, we have confirmed that code 
81345-GZ is a column II code to column I code 0089U. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for the TERT (telomerase reverse transcriptase) 
laboratory services (81345-GZ) provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Office Visit provided on December 14, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Office Visit. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
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 Office Visit provided on December 14, 2021 by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on December 6, 
2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you had this service done before 
and there was no coinsurance charged. The Plan denied your request. The Plan says the provider confirmed the 
proper code was billed properly and the enrollee has not had the same injection prior. Therefore, the proper 
coinsurance was applied for the service that was rendered. 
 
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 each In-network Medicare-covered Part B drug. The total amount charged for the injection was 
$445.57 with a coinsurance of $89.11 ($445.57 total amount allowed x 20% coinsurance). 
 
  You have been asked to pay a $89.11 coinsurance for the injection. The injection 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 an injection 
provided on December 6, 2021.