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

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a participating 
provider on April 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you had a limit for these 
services. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 7, 2021. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a 
participating provider on April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye appointment provided on July 26, 
2022. 
 
You asked the Plan to waive the copayment for an eye appointment. You say that this was supposed to be an 
annual eye visit. 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 $45 
copayment for vision care. 
 
You have been asked to pay a $45 copayment for an eye appointment. This item/service falls within the vision 
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 eye appointment provided on 
July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound therapy (97035) provided on February 4, 2022 
and February 8, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy or by Medicare. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the ultrasound therapy (97035) provided on February 4, 2022 and 
February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on June 
07, 2022. 
 
You asked the Plan to reduce the copayment for a specialist office visit. You say that you were told the 
provider was in-network 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 $55 
copayment for out-of-network specialist visit. 
 
You have been asked to pay a $55 copayment for a specialist office visit. This item/service falls within the out-
of-network specialist visit 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 a specialist 
office visit provided on June 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the onabotulinumtoxina (Botox) injections 
provided on February 11, 2022. 
 
You asked the Plan to waive the coinsurance for the onabotulinumtoxina (Botox) injections. You say that you 
feel the coinsurance is incorrect. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the onabotulinumtoxina (Botox) injections. This item/service 
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 the onabotulinumtoxina (Botox) injections provided on February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy on tooth #19 (D3330) provided on 
January 11, 2022. 
 
You asked the Plan to pay for endodontic therapy. You say that a root canal is a covered service. The Plan 
denied your request. The Plan says endodontic therapy (D3330) is not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
endodontic therapy on tooth #19 (D3330) provided on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator and a chest compression device. 
 
You asked the Plan to pre-approve a home ventilator and a chest compression device. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator and a chest 
compression device. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the provided primary source documentation does not contain sufficient detailed information in the 
medical record to justify the treatment selected. The enrollee could be treated with a bilevel positive airway 
pressure (BiPAP) machine with average volume-assured pressure support (AVAPS) capability. The plan has 
indicated coverage for such a device is available upon request. The enrollee does have an enumerated 
neuromuscular condition for which coverage of a high frequency chest wall oscillation device is available 
under the coverage criteria. The record provided is insufficient to establish that there is well-documented 
failure of standard treatments to adequately mobilize retained secretions. The elements of the coverage criteria 
are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator and a chest compression device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a home ventilator and a chest compression device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a magnetic resonance imaging (MRI) scan 
provided on April 28, 2022. 
 
You asked the Plan to waive the cost for an MRI. You say that you are contesting the $6 coinsurance for the 
contrast used in this MRI. 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies and a 20% coinsurance 
Medicare Part B prescription drugs. The allowed amount of this contrast was $30, resulting in a coinsurance of 
$6 ($30 x 20% = $6).  
 
You have been asked to pay a $100 copayment, and a $6 coinsurance for an MRI. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies and Medicare Part B prescription drugs 
benefit category ($100 + $6 = $106). 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 for a magnetic resonance imaging (MRI) scan provided 
on April 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the out-of-network inpatient hospital care 
provided on May 17, 2022, to May 25, 2022. 
 
You asked the Plan to waive the copayment for the out-of-network inpatient hospital care. You say that it was 
an emergency situation, and you did not know the hospital was out-of-network. 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 $4,000 
copayment for inpatient hospital care (out-of-network). 
 
You have been asked to pay a $4,000 copayment for the out-of-network inpatient hospital care. This 
item/service falls within the inpatient hospital care (out-of-network) 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. The file shows the Plan verified the hospital is not 
a network facility. Per the EOC, there is a $500 copayment for days 1-20 for out-of-network inpatient care. Your stay lasted 8 days, for a total of $4,000. Therefore, we decided that the Plan does not have to waive the 
copayment for the out-of-network inpatient hospital care provided on May 17, 2022, to May 25, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve specialty care outside of the Plan's network of providers. 
 
You asked the Plan to pre-approve specialty care outside of the Plan's network. You say that you want 
treatment, however; you do not want an abdominoperineal resection (APR) offered in-network and you are 
interested in other treatment options such as Chemoradiotherapy (chemoRT) with close follow-up at a tertiary 
facility, such as at the requested out-of-network provider. The Plan denied your request. The Plan says that the 
enrollee can be seen by either an in-network surgical oncologist, colon and rectal surgery specialist, or a 
medical oncology specialist. 
 
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. In this case, the file shows that the enrollee has a history of prostate cancer with 
newly diagnosed rectal cancer. The Plan providers discussed an APR, which would lead to a permanent 
colostomy bag, and the enrollee would like further options for treatment, such as chemoRT, to which the Plan 
providers agree. We sent a request for additional information to the Plan to confirm that the Plan providers 
could offer the same type of treatment options, however; the Plans response was they did not know if any 
other treatment options could be offered to the enrollee by the Plan providers that would not result in a 
permanent colostomy. We find that the Plan has not provided enough evidence to show that the Plan providers 
can offer additional treatment options for this enrollee with a history of prostate cancer with newly diagnosed 
rectal cancer. Therefore, we decided that the Plan has to pre-approve specialty care outside of the Plan's 
network of providers.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-rays of the leg aortas provided on 
August 18, 2021, to August 19, 2021. 
 
You asked the Plan to waive the copayment for the x-rays of the leg aortas. You say that you did not have x-
rays after you were released from the ER. 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 $105 
copayment for basic radiological services at an outpatient hospital. 
 
You have been asked to pay a $105 copayment for the x-rays of the leg aortas. This item/service falls within 
the basic radiological services at an outpatient hospital 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 x-rays of the leg aortas provided on August 18, 2021, to August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral complete series of radiographic images (D0210) 
provided on June 16, 2022. 
 
You asked the Plan to pay for intraoral complete series of radiographic images (D0210). You say that you went 
to the provider for an extraction, you were not expecting them to do an exam with x-rays. The Plan denied your 
request. The Plan says this service is not covered under your Plan. 
 
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. Intraoral complete series of 
radiographic images are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested intraoral complete series 
of radiographic images (D0210) are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for intraoral complete series of radiographic images (D0210) provided on June 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on March 22, 2022. 
 
You asked the Plan to pay for the physicians services. The Plan denied your request. The Plan says the 
provider is listed on the CMS opt out database effective February 10, 2016. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
physicians services provided on March 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Aurora Zip procedure. 
 
You asked the Plan to pre-approve an Aurora Zip procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Aurora Zip procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Aurora Zip procedure is experimental in spine surgery. More research is needed 
to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Aurora Zip procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Aurora Zip procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve a crown. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
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 a 
crown (D2750) provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound debridement services (procedure code 11042) 
provided to the enrollee on April 7, 2022. 
 
You asked the Plan to pay for the services. You say that debridement of the wounds indicated were performed 
judiciously and at appropriate intervals. The Plan denied your request. The Plan says this was not submitted 
with an appropriate diagnosis. 
 
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 11042 is "Debridement, subcutaneous tissue (includes 
epidermis and dermis, if performed); first 20 sq cm or less." 
 
We asked our coder 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 supported by the medical records. Our reviewer found that the medical documentation does 
not support the use of either this procedure code or diagnosis code. This is a wound care assessment, and there 
is a more appropriate CPT code and diagnosis code to use.  
We looked at this coder'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 wound debridement services (procedure code 11042) provided to the enrollee on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for simple extraction (D7111) provided on July 19, 2022. 
 
You asked the Plan to pay more for dental services. You say that the Plan is supposed to pay half of an 
extraction, you say the Plan did not pay the correct amount. The Plan denied your request. The Plan says the 
claim was processed correctly. 
 
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 Plan is only obligated to pay 50% 
of the allowed amount for the simple extraction. You are responsible for any amount greater than what the Plan 
pays to the in-network provider. You have been asked to pay $62, which is 50% of the allowed amount. The 
allowed amount is $124 (50% x $124 = $62). Therefore, we decided that the Plan does not have to pay more 
for simple extraction (D7111) provided on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services provided on June 24, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmology services. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-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 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 ophthalmology services provided on June 24, 
2022, by an out-of-network (OON) provider.