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

 
We decided that the Plan does not have to waive the cost-sharing for an emergency room (ER) visit provided 
on January 4, 2022 . 
 
You asked the Plan to waive the cost-sharing for the ER visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $125 
copayment for Emergency care.  
 
 
  You have been asked to pay a $125 copayment for the ER visit. 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-sharing for an emergency room (ER) visit provided on January 4, 2022. .
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gastroenterology consultation to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the gastroenterology consultation. You say that you feel more comfortable 
going out-of-network because they see more cases like yours. The Plan denied your request. The Plan says the 
provider is out-of-network 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the gastroenterology consultation in this appeal. We found no exception that would 
require the Plan to pre-approve the gastroenterology consultation. The records provided for review do not show 
that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve 
the gastroenterology consultation to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health care provided on October 21, 2021, to 
November 5, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mental health care. You say that the mental health care was medically 
necessary. You say you were unable to find an appropriate facility locally. The Plan denied your request. The 
Plan says the enrollee was self-referred, and no prior authorization was obtained. 
 
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 mental health care in this appeal. The Plan did not pre-approve the 
mental health care. We found no exception that would require the Plan to pay for the mental health care. Therefore, we decided that the Plan does not have to pay for mental health care provided on October 21, 2021, 
to November 5, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit and arthrocentesis 
provided on January 12, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit and arthrocentesis. You say that you that you 
made an appointment for a visco injection and discovered after the injection it was a steroid and not the visco. 
The Plan denied your request. The Plan says you have been charged the correct copayment and coinsurance 
amounts. 
 
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 each Medicare-covered visit with an in-network specialist and a $250 copayment for each 
Medicare-covered, in-network outpatient hospital facility visit. 
 
 You have been asked to pay a $45 copayment for the specialist visit. You have also been asked to pay $103.21 
for the arthrocentesis, which is less that the standard $250 copayment.  The total amount you owe is $148.21 
($45 + $103.21 = $148.21) The specialist visit falls within the Physician/Practitioner services, including 
doctors office visits benefit category. The arthrocentesis falls within the Outpatient hospital 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 specialist visit and waive the 
coinsurance for an injection provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the provisional crown (D2799) provided on August 19, 2021. 
 
You asked the Plan to pay for the dental service. You say that you went in for a crown. You say that the dentist 
advised you needed a root canal first. You also say that the provisional crown was necessary as you had an 
open tooth. The Plan denied your request. The Plan says the claim denied correctly. 
 
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 provisional crown is not among 
those covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pay for the provisional crown (D2799) provided on 
August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testosterone pellets 75 mg (S0189). 
 
You asked the Plan to pre-approve testosterone pellets 75 mg. You say that the services are necessary. The Plan 
denied your request. The Plan says code S0189 has a status indicator of I, which indicates that this service is 
not valid for Medicare purposes. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of testosterone pellets 75 mg billed using code S0189 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve testosterone pellets 75 mg (S0189).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins 
when required (D2950) provided on January 12, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the crown and core buildup. You say that you were just paid for a procedure 
rendered by the same dentist on October 12, 2021. You also say that you are wondering if the treating provider 
is no longer in-network. The Plan denied your request. The Plan says these services are not covered if they are 
performed OON. 
 
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 requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) and core buildup, including any pins when required (D2950) provided on January 12, 2022 by an out-
of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on September 
5, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are experiencing a 
hardship and cannot afford the copayment. 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 each one-way Medicare-covered ground ambulance trip. 
.  
 
You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 ambulance 
services provided on September 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), crown 
(D2740), and core buildup, including any pins when required (D2950) provided on January 11, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, crown, and core buildup. You say 
that your provider has been in-network in the past, and claims were paid previously. You also say that your 
provider contacted the Plan prior to rendering the services and was advised that all of the proposed services 
were approved. The Plan denied your request. The Plan says services performed by an OON provider are not 
covered because your healthcare plan does not have OON benefits. The Plan also says that neither you nor your 
provider contacted the Plan prior to the date of service to verify benefits and provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the problem focused limited oral evaluation (D0140), crown (D2740), and core buildup, including any pins 
when required (D2950) provided on January 11, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta (J3304). 
 
You asked the Plan to pre-approve Zilretta. You say that please see attached documents to appeal this denial. 
All criteria has been met in the attached office notes. The Plan denied your request. The Plan says the records 
do not support that the enrollee has met the criteria. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Zilretta. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Plan requires a trial of generic triamcinolone acetonide injection before they will approve 
the requested drug, Zilretta. Based on the medical records provided there is no indication that the enrollee has 
tried and failed the required drug. There is no indication that the Plan's required drug would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta (J3304).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4260 x 2) and bone replacement graft 
(D4263 x 2) provided on January 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that oral surgery services are covered at 50%. You 
also say that you would not have had the services done had you known the services would not be covered. The 
Plan denied your request. The Plan says the services you received are not listed as covered. 
 
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 osseous surgery and bone 
replacement graft are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the osseous surgery (D4260 x 2) and bone replacement graft (D4263 x 2) provided on January 
25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have reduce the $150 copayment for a sleep study performed on 
December 9, 2021. 
 
You asked the Plan to reduce the $150 copayment for a sleep study performed on December 9, 2021. You say 
that you were told everything was covered by your copayment and your copayment would be $30. The Plan 
denied your request. The Plan says you pay a $0 or $150 copayment for In-Network Medicare-covered 
diagnostic procedures and tests; $0 copayment for EKG and diagnostic colorectal screenings, $150 copayment 
for all other diagnostic procedures and tests. 
 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 $150 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $150 copayment for sleep study. Sleep studies fall 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 reduce the $150 
copayment for a sleep study performed on December 9, 2021.  
 
Your complaint about being given the incorrect information about your cost sharing 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray of the facial bones (70150) billed for date of service 
September 28, 2021. 
 
You asked the Plan to pay for an X-ray of the facial bones. You say that you have provided records to support 
the service rendered. The Plan denied your request. The Plan says rules for payment have not been met because 
the available records do not support the service 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, the CPT Code Manual definition of code 70150 is "Radiologic examination, facial bones; complete, 
minimum of 3 views." 
 
We find that CPT code 70150 is not supported in the medical record. Specifically, the case record does not 
contain medical records of an X-ray of the facial bones rendered on the date of service. Based on this 
information, we decided that Medicare rules for coverage of an X-ray of the facial bones have not been met. 
Therefore, we decided that the Plan does not have to pay for an X-ray of the facial bones (70150) billed for 
date of service September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and 
prophylaxis - adult (D1110) provided November 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral exam and dental cleaning. You say that this is the only dentist 
that you can drive to. The Plan denied your request. The Plan says these services are not covered because they 
were provided OON without prior authorization. 
 
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 and dental cleaning when the services are provided in-network. 
 
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the 
Plan. The Plan did not pre-approve the OON services. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of the 
periodic oral exam and dental cleaning have not been met. Therefore, we decided that the Plan does not have to 
pay for the periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided 
November 8, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on December 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
drug testing at issue. We found no exception that would require the Plan to pay for the drug testing. The 
records provided for review do not show that the drug testing was urgent or emergent. Therefore, we decided 
that the Plan does not have to pay for the drug testing provided on December 6, 2021, by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve for the acute inpatient hospital admission. 
 
You asked the Plan to pre-approve for acute inpatient hospital admission. You say that you need these services 
to be covered after you have surgery. The Plan denied your request. The Plan says that the requested admission 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 for acute inpatient hospital admission. 
Our reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. 
Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that your necessary hospital care (including earlier ED and/or observation care) would 
span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital admission have been met. Therefore, we decided that 
the Plan has to pre-approve for the acute inpatient hospital admission.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-walk system represented by code L6981, a 
protective outer surface covering represented by code L5962, and a lower limb prosthesis represented by code 
L5968. 
 
You asked the Plan to pre-approve codes L6981, L5962, and L5968. You say that your foot and hydraulics is 
broken, and the item is no longer under warranty. You say that you cannot walk, and it is not safe for you to 
wait. The Plan denied your request. The Plan says the requested items which remain in dispute do not meet the 
Medicare criteria for coverage, as they are not medically reasonable and necessary.  
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 codes L6981, L5962, and L5968. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the treating medical provider documentation does not support that the enrollee is a 
K3 ambulator. The enrollee needs help with walking, shopping, housework and uses a cane. The enrollee does 
not exercise and participates in light physical activity. The flex-walk system represented by code L6981, and a 
lower limb prosthesis represented by code L5968 exceeds the enrollee's medical needs. The documentation 
does not reveal that the enrollee has special needs for protection against unusually harsh environmental 
situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is 
afforded by the standard cover. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes L6981, L5962, and L5968 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a flex-walk system represented by code L6981, a protective outer surface 
covering represented by code L5962, and a lower limb prosthesis represented by code L5968.