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

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210) provided on December 12, 2022. 
 
You asked the Plan to pay for the extraction. You say that the dentist advised you that the distal root was 
infected upon removal and inspection, which is why the tooth was removed. You also say that you view this as 
a medical reason. The Plan denied your request. The Plan says this service is not covered under the benefit 
package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on December 
12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 03, 2021. 
 
You asked the Plan to pay for an office visit. You say that you were denied in error. 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 August 03, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on October 04, 2022. 
 
You asked the Plan to pay for psychotherapy services. You say that you were not advised that this provider was 
out-of-network. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy services 
provided on October 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on December 22, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the requested 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 service was exhausted on date of service March 4, 2020. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician home visit services provided on December 12, 
2022. 
 
You asked the Plan to pay for physician home visit 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 physician home visit 
services provided on December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the nuclear medicine scan provided on 
October 27, 2022. 
 
You asked the Plan to reduce the copayment for the nuclear medicine scan. You say that you had seen different 
amounts listed for these services and wanted to make sure you were being charged the correct amount. 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 $400 
copayment for in-network outpatient diagnostic tests. 
 
You have been asked to pay a $400 copayment for the nuclear medicine scan. This item/service falls within the 
in-network outpatient diagnostic 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. Therefore, we decided that the Plan does not have to reduce the copayment for 
the nuclear medicine scan provided on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision care office visit provided on 
December 14, 2022. 
 
You asked the Plan to waive the copayment for the vision care office visit. You say that you were only there 
for five minutes and did not see a doctor. 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 $30 
copayment for vision care visits. 
 
You have been asked to pay a $30 copayment for the vision care office visit. This item/service falls within the 
vision care 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 the vision care office 
visit provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wellness visit provided on October 24, 2022. 
 
You asked the Plan to pay for wellness visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wellness visit provided 
on October 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 5, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that if you had the energy to walk to stay on 
your feet and did not suffer from the painful intestinal twisting you were experiencing you would not have 
called the ambulance. The Plan denied your request. The Plan says we do not have sufficient information to 
review your case. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment.  Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the 
services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
with the provider that the claim was submitted to the primary insurance carrier, but they have not received the 
primary insurance payment information. Moreover, multiple outreach attempts were made to reach you but 
calls were not answered. As the secondary insurer, the Plan cannot be held responsible for the ambulance 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the x-ray and the EKG provided on 
December 8, 2022. 
 
You asked the Plan to waive the cost share for the x-ray and EKG. You say that the tests are part of the routine 
exam. 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. Your 
contract with the Plan says that there is a $800 deductible and a 10% coinsurance which applies to outpatient 
diagnostic tests.  
 
You have been asked to pay $31.46 towards your deductible for the x-ray. You have also been asked to pay 
$13.45 towards your deductible for the EKG. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $800 deductible which applies to outpatient diagnostic tests. This cost sharing is a 
contractual obligation that had not been met at the time the x-ray and EKG was received on December 8, 2022. 
 
You have also been asked to pay $3.50, which is 10% coinsurance of the allowed amount for the x-ray ($34.96 
allowed amount x 10% = $3.50). You have also been asked to pay $1.49, which is 10% coinsurance of the 
allowed amount ($14.94 allowed amount x 10% = $1.49). These items or services you asked the Plan to waive 
the cost share for fall within the outpatient diagnostic 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. Therefore, we decided that the Plan does not have 
to waive the cost share for the x-ray and the EKG provided on December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on December 14, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the Plan told you authorization was not 
needed. The Plan denied your request. The Plan says the enrollees contract does not allow coverage for this 
out-of-network service. 
 
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, pre-approved care, or those specified services covered under the enrollees POS benefit. 
 
The requested provider in this case is not a network provider with the Plan. The service provided is not among 
those covered under the POS benefit. 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 December 14, 2022, by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Morphine (J2274), home infusion therapy (S9328), and 
Bupivacaine (J3490) provided from February 1, 2022 to August 2, 2022, by an out-of-network (OON) 
provider. 
 
  You asked the Plan to pay for the Morphine, home infusion therapy, and Bupivacaine. The Plan denied your 
request. The Plan says these services were performed by a non-participating provider and services from non-
participating providers are not covered unless preauthorized. The Plan also says a valid referral was not found 
on file for the service in question nor was there an authorization on file for the non-contracted provider. 
 
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 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 Morphine (J2274), home infusion therapy 
(S9328), and Bupivacaine (J3490) provided from February 1, 2022 to August 2, 2022, by an out-of-network 
(OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an esophageal balloon distension (EndoFlip) study. 
 
You asked the Plan to pre-approve an EndoFlip study. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is experimental and 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 an EndoFlip study. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records in this case do not document what additional information is 
required by the EndoFlip study given the endoscopy, biopies and manometry that has already been performed. 
Provided medical records and review of the current peer-reviewed medical literature do not document that use 
of the EndoFlip test has been shown in controlled studies to result in long term health benefits in patients with 
dysphagia and gastroesophageal reflux with achalasia as compared to more established methods of testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EndoFlip study have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an esophageal balloon distension (EndoFlip) study.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the onabotulinumtoxina injection and drug 
administration provided on December 9, 2022. 
 
You asked the Plan to reduce the cost share for the injection and drug administration. You say that you were 
charged incorrectly. 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 20% 
coinsurance for in-network Medicare Part B prescription drugs. Your contract with the Plan also clearly says 
that you must pay a $325 copayment for in-network surgery services provided in an outpatient hospital. You have been asked to pay $249.16 coinsurance, which is 20% of the allowed amount for the injection 
($1,245.80 allowed amount x 20% = $249.16). This item/service falls within the Medicare Part B prescription 
drugs benefit category. 
 
You have also been asked to pay a $256.87 copayment, which is less than the standard copayment for the drug 
administration. This item/service falls within the outpatient surgery, including services provided at hospital 
outpatient facilities 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 reduce the cost share for the 
onabotulinumtoxina injection and drug administration provided on December 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression devices (E0650, E0673, 
E0666). 
 
You asked the Plan to pay for intermittent limb compression devices. You say that the items were medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare for the purpose of prevention of venous thromboembolism is a preventive service. Items that are used 
for a preventative service or function are excluded from coverage under the Medicare durable medical 
equipment benefit. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
devices (E0650, E0673, E0666).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on September 12, 2022. 
 
You asked the Plan to pay for drug testing. You say that this is supported in the records. 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 drug testing provided on 
September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Artacent wound skin substitute (84169). 
 
You asked the Plan to pre-approve the Artacent wound skin substitute. You say that the service is medically 
necessary. The Plan denied your request. The Plan says this service is consdiered experimental. 
 
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 Artacent wound skin substitute. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found Artacent wound skin substitute has not been medically proven to be effective and, 
therefore, is considered investigational. 
 
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 Artacent wound skin substitute have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Artacent wound skin substitute (84169).
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 the CGM. You say that the enrollee needs to check their blood sugar 3 to 4 
times daily. The Plan denied your request. The Plan says the Medicare criteria was not 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 provided by the prescribing physician says 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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).