Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freedom Plie 3 knee (L5828, L5845, L5848, L5856) 
with rotation unit (L5984) and lithium battery charger (L7368). 
 
You asked the Plan to pre-approve the Freedom Plie 3 knee and related accessories. You say that this 
equipment is medically necessary. The Plan denied your request. The Plan says the requested items exceed the 
enrollee's needs beyond what has already been approved. 
 
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 Freedom Plie 3 knee and related 
accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation is not clear in the physician 
progress notes that you require the Freedom Plie knee over a K3 mechanical knee. The manufacturer website 
for the Freedom Plie notes that this knee has IP67 protection which means it is protected from immersion in 
water with a depth of up to 1 meter (or 3.3 feet) for up to 30 minutes. Additionally, this knee can be used for 
high K3 or K4 users, as the knee offers opportunity to jog, or participate in a sport where change of pace or 
direction is required. The physician documentation does not reveal that you require protection from 30 minutes 
of water immersion up to 1 meter, participates in a sport where change of pace or direction is required or that 
the patient jogs. You are noted to have been participating in home physical therapy which indicates that you are 
homebound and leaving the home is a taxing effort. There are no objective strength measurements in the 
physician notes of the upper extremities indicating why the patient requires this therapy. The physician 
documentation does not support why you are unable to use a mechanical knee. The Freedom Plie also has 
designer fairing options which also are not a medical necessity. As the requested knee is not medically 
reasonable and necessary, the related accessories will also be denied. 
 
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 Freedom Plie 3 knee and related accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Freedom Plie 3 knee (L5828, L5845, L5848, L5856) 
with rotation unit (L5984) and lithium battery charger (L7368).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-
rays (D0274) provided on February 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not satisfied with the work you had 
done from the previous provider. The Plan denied your request. The Plan says a comprehensive oral evaluation 
is covered once every 3 plan years. The Plan says that bitewing x-rays are covered once per plan year. The Plan 
also says that the frequency limits have been exceeded. 
 
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 and the services are listed as covered, the frequency limits have been exceeded. Comprehensive oral evaluation is covered once every 3 plan years. 
The record shows that the Plan paid for a comprehensive oral evaluation that you received on January 4, 2022. 
Bitewing x-rays are covered once per plan year. The record shows that the Plan paid for bitewing x-rays that 
you received on January 4, 2022. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth 9. 
 
You asked the Plan to pre-approve a crown for tooth 9. You say that you need a crown. The Plan denied your 
request. The Plan says there is no evidence of decay or missing crown to support the need for replacement. 
 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 Plan covers a crown for 
tooth 9 when the services are medically necessary and reasonable.  
 
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 crown for tooth 9. Our reviewer says 
that a replacement crown for tooth 9 is not medically necessary. Our physician reviewer found that a review of 
the documentation provided revealed that tooth 9 has a crown in place. The crown did not appear to be 
defective with recurrent caries or fracture and there was no narrative indicating the reason for replacement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown for tooth 9 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth 9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says services provided out-of-network are 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 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 dental services provided on January 10, 2022, by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, conventional air services, transport, 
one way (A0431) and rotary wing air mileage (A0436) provided on April 6, 2021. 
 You asked the Plan to pay for the air ambulance services. You say that the enrollee was transported for a closed 
head injury. You say that the ground transport would have been 42 minutes as opposed to 17 minutes by air. 
You also say that the transport was medically necessary. The Plan denied your request. The Plan says the air 
ambulance services were not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found the provided 
documentation does not support that the enrollee's condition was such that the time needed to transport a 
patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or 
seriously endangered their health. The reviewer found that the enrollee had swelling and abrasions of the nose 
but no other noted abnormalities. The documentation states that ground transport time was 42 minutes. The 
reviewer found that a drive time of 42 minutes would not have posed a threat to the enrollee's survival or 
seriously endangered their health. Therefore, the reviewer found that the air ambulance services were 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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the ambulance service, conventional air services, transport, one way (A0431) and 
rotary wing air mileage (A0436) provided on April 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a single-photon emission computed 
tomography (SPECT). 
 
You asked the Plan to waive the copayment for single-photon emission computed tomography (SPECT). You 
say that you cannot afford the copayment. The Plan denied your request. The Plan says you are responsible for 
this copayment under your contract. 
 
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 for CT scans, MRIs, PET scans, and nuclear cardiac imaging tests. 
 
You have been asked to pay a $325 copayment for a single-photon emission computed tomography (SPECT). A single-
photon emission computed tomography (SPECT) falls within the CT scans, MRIs, PET scans, and nuclear cardiac 
imaging tests 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prednisone tablets. 
 
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 self-administered drugs are not covered. 
 
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 prednisone tablets.  
 
Benefits for these services 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided January 
16, 2022 to January 27, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that in your old plan there 
was no copayment for inpatient services. You say that you went to the emergency room, and you were admitted 
therefore you say that you should not have a copayment. 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 $200 
copayment each time you are admitted to an acute care hospital you pay $200 per day for days 1-5 and $0 after 
day 5.  You have been asked to pay a total of $1,000 for the inpatient hospital stay ($200/day x 5 days = $1,000). The 
inpatient hospital stay 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 an inpatient hospital stay provided January 16, 2022 to January 27, 2022.
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 
November 19, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you cannot afford the 
copayments under this plan. The Plan denied your request. The Plan says you have been 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 $45 
copayment for a specialist office visit.  
 You have been asked to pay a $45 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 November 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid (64400) 
provided January 21, 2022. 
 
You asked the Plan to pay for the injection services. You say that the enrollee had multiple exams on this date 
of service. Please reconsider for processing. The Plan denied your request. The Plan says the procedure code is 
inconsistent with the modifier used. 
 
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 64400 is injection(s), anesthetic agent(s) and/or steroid; 
trigeminal nerve, each branch. (ie, ophthalmic, maxillary, mandibular). 
 
We find that CPT code 64400 is not supported in the medical record. Specifically, the medical records indicate 
that the enrollee was experiencing pain in the front/left tooth and left front jaw, however the appropriate 
anatomical modifier was not appended to the service indicating the left side. A corrected claim must be 
submitted. Based on this information, we decided that Medicare rules for coverage of the injection services 
have not been met. Therefore, we decided that the Plan does not have to pay for the injection(s), anesthetic 
agent(s) and/or steroid (64400) provided January 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 18, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that youve had this procedure in the 
past and you never had any additional copays. The Plan denied your request. The Plan says the copayment 
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 a $115 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-
network physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
You have been asked to pay $79.96 copayment for an ultrasound which is less than the standard $115 
copayment. An ultrasound falls within the radiological diagnostic services, not including x-rays 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 January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92004) provided on January 
7, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you did not ask for this to happen, 
nor did you sign anything. You also say that you did not get your prescription. The Plan denied your request. 
The Plan says the copayment amount that you were charged is correct. 
 
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. 
 
We looked at the file and the Plan's rules. The contract clearly states that you are responsible for a $35 copay 
for Level 1 physician services to diagnose and treat diseases and conditions of the eye. Based on this 
information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we 
decided that the Plan does not have to waive the copayment for the eye exam (92004) provided on January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the periodic oral evaluation - 
established patient (D0120) and prophylaxis - adult (D1110) provided January 13, 2022, the intraoral - 
periapical first radiographic image (D0220) and crown - porcelain/ceramic (D2740) provided January 25, 2022, 
and the resin-based composite - two surfaces, posterior (D2392) provided February 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to provide additional payment for the periodic oral exam, dental cleaning, intraoral x-ray, 
crown and filling. You say that your coverage doesn't align with what you were told when you signed up for 
the Plan. The Plan denied your request. The Plan says the services have been paid correctly according to your 
OON 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 Plan covers the periodic 
oral exam, dental cleaning, intraoral x-ray, crown and filling with 0% coinsurance. You may be billed by the 
out-of-network provider for any amount greater than the payment made by the Plan to the provider. 
 
We looked at the file, and Medicare rules. The Plan provided documentation showing that they covered the full 
allowed amount for the services at issue. You have been asked to pay the difference between the Plans allowed 
amount and the total charge billed by the OON provider. This means you have been asked to pay the correct 
amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide 
additional payment for the periodic oral evaluation - established patient (D0120) and prophylaxis - adult 
(D1110) provided January 13, 2022, the intraoral - periapical first radiographic image (D0220) and crown - 
porcelain/ceramic (D2740) provided January 25, 2022, and the resin-based composite - two surfaces, posterior 
(D2392) provided February 14, 2022, by an out-of-network (OON) provider.  
 
Your complaint about feeling that your current coverage does not match what was explained when you decided 
to sign up for the Plan 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 pay for the limited oral evaluation (D0140) provided on January 19, 2022. 
 
You asked the Plan to pay for the dental service. You say that you cannot afford to pay this bill. The Plan 
denied your request. The Plan says limited oral evaluation is not listed as a covered service. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on January 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on January 28, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you feel you do not owe this amount. The 
Plan denied your request. The Plan says the copayment 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 a $225 
copayment for advanced imaging services such as CT, CTA, MRI, MRA, nuclear stress test, PET scans, 
SPECT. 
 
 You have been asked to pay a $204.78 copayment for the MRI which is less than the standard $225 copayment. 
The MRI falls within the 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 the MRI provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported crown (D6058) for tooth # 14. 
 
You asked the Plan to pre-approve the dental service. You say that you signed up with this plan for the dental 
coverage. You say that you need to have this crown placed. You also say that you needed the tooth extracted 
after 3 root canals. The Plan denied your request. The Plan says abutment supported crown is not listed as a 
covered service. 
 
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 an 
abutment supported crown (D6058) for tooth # 14.