Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 99239 and 99236 provided from October 19, 2021, to 
October 20, 2021. 
 
You asked the Plan to pay for procedure codes 99239 and 99236. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
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 Plan has not provided enough evidence to support the denial of 
payment for these services based on Medicare criteria. The Plan did not provide the CMS-1500 form to verify 
that these inpatient procedure codes were submitted on an outpatient claim and that multiple place of service 
codes were reported. It is the Plan's responsibility to send all supporting evidence the denial was based on. 
Therefore, we decided that the Plan has to pay for procedure codes 99239 and 99236 provided from October 
19, 2021, to October 20, 2021.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on September 24, 2022. 
 
You asked the Plan to pay for nursing facility visit. You say that you are appealing the claim payment denial. 
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 nursing facility visit 
provided on September 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride (D1208) provided on July 
6, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are a Medicare valid provider, and the 
services should be paid at an in-network level. The Plan denied your request. The Plan says the denial of 
payment for this service is correct because the topical application of fluoride not covered by the Plan. Also, the 
rendering provider is an out-of-network provider. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
topical application of fluoride (D1208) provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit provided on October 14, 
2022. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that you did not know the provider 
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 40% 
coinsurance for out-of-network physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $41.54, which is 40% coinsurance of the allowed amount for an office visit 
($103.84 allowed amount x 40% coinsurance = $41.54). This item/service falls within the 
physician/practitioner services, including doctor's 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 coinsurance for an office visit provided on October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share of an office visit provided on October 10, 2022 
 
You asked the Plan to reduce the cost share of an office visit. You say that you thought the provider was in-
network and you feel you should only pay the copayment. 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 $750 deductible which applies to physician/practitioner services, 
including doctors office visits. 
 
The item or service you asked the Plan to reduce the cost share falls within the physician/practitioner services, 
including doctors office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $750 deductible which applies to Physician/Practitioner services, including doctors 
office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was 
received on October 10, 2022. Therefore, we decided that the Plan does not have to reduce the cost share of an 
office visit provided on October 10, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D1110, D0120, D2740, D2391) provided on 
April 14, 2022 to September 7, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services denied correctly as they do not 
fall within your plan benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services (D1110, D0120, 
D2740, D2391) provided on April 14, 2022 to September 7, 2022
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. 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. 
 
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 Euflexxa. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
Orthovisc, Synvisc or Synvisc-One would likely be less effective, and/or would likely have adverse effects for 
the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core build-ups (D2950 x 8), the retainer crowns 
(D6740 x 2), and the pontic (D6245). 
 
You asked the Plan to pre-approve the core build-ups (D2950 x 8), the retainer crowns (D6740 x 2), and the 
pontic (D6245). You say that you are appealing the denied dental services. The Plan denied your request. The 
Plan says the services are not covered 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 core build-ups (D2950 x 8), the 
retainer crowns (D6740 x 2), and the pontic (D6245) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve the core build-ups (D2950 x 8), the retainer 
crowns (D6740 x 2), and the pontic (D6245).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-ray provided on August 03, 2022. 
 
You asked the Plan to waive the copayment for X-ray. You say that you are disputing the share cost. 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 $70 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $70 copayment for X-ray. This item/service 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 X-ray provided on August 03, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out of network denosumab injection 
provided on August 8, 2022. 
 
You asked the Plan to waive the coinsurance for an out of network denosumab injection. You say that you 
should not have another payment due, you feel the plan should pay for all of it. 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug or item is $1335.60, 
resulting in a coinsurance amount of $267.12 ($1335.60 x 20% = $267.12). 
 
You have been asked to pay a $267.12 coinsurance for an out of network denosumab injection. 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 an out of network denosumab injection provided on August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites (D2392) for tooth #4 and #12 
provided on September 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are supposed to be covered 100% for 
fillings a year and there was an approved predetermination. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. Also, it was verified there was no 
predetermination ever sent for the dental services in question. 
 
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 
show the Plan paid for a resin-based composite on February 2, 2022, and on May 17, 2022; therefore, your 
benefit was exhausted on the date of service of May 17, 2022. Therefore, we decided that the Plan does not 
have to pay for the resin-based composites (D2392) for tooth #4 and #12 provided on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on June 29, 
2022. 
 
You asked the Plan to pay for the bone replacement graft. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your 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 a bone 
replacement graft (D7953) provided on June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on September 23, 
2021. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the provider was asked to see the 
enrollee for a same day appointment, and authorization could not be submitted. 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 the subsequent nursing 
care provided on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) and a 
surgical stent (D5982) provided on July 15, 2021, to August 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dental services provided were necessary for 
your health. The Plan denied your request. The Plan says the provider has opted out of Medicare. 
 
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 a 
comprehensive periodontal evaluation (D0180) and a surgical stent (D5982) provided on July 15, 2021, to 
August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on September 28, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 January 26, 2022 and 
May 25, 2022. Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on 
September 28, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 03, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was in a nursing home and a 
network provider could not be chosen. 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 the laboratory services 
provided on June 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to place a metal post in jaw (procedure code 
D6010), extension on metal post in jaw (D6057), and a Tooth-shaped cap (D6058) on tooth #30 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your 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 pre-approve 
surgery to place a metal post in jaw (procedure code D6010), extension on metal post in jaw (D6057), and a 
Tooth-shaped cap (D6058) on tooth #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (A4595) provided on April 
20, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (A4595) provided on April 20, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
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. Our reviewer says 
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the enrollee has 
severe chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), with repeated 
hospitalizations for acute on chronic respiratory failure. The enrollee was admitted on November 13, 2022, 
with COVID-19 pneumonia and exacerbation of Heart failure with reduced ejection fraction (HFrEF), and CO2 narcosis, requiring intubation.  There is no arterial blood gas (ABG) test done while stable, but chronic CO2 
retention seems likely. The enrollee may benefit from BiPAP with AVAPS and a backup rate during sleep as 
an outpatient. There is no documentation that this has been tried (with documentation of compliance) as an 
outpatient and failed according to Medicare criteria. Medicare does not cover a home ventilator when used as 
BiPAP. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a physical therapy visit provided on June 
28, 2022, by an out-of-network provider. 
 
You asked the Plan to waive the deductible for a physical therapy visit. You say that the physical therapy visits 
should have been processed as in-network and was verified prior to services being rendered. 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 $750 deductible which applies to outpatient rehabilitation services.  
 
  The item or service you asked the Plan to waive the deductible for falls within the Outpatient Rehabilitation 
Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $750 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual 
obligation that had not been met at the time a physical therapy visit was received on June 28, 2022. Therefore, 
we decided that the Plan does not have to waive the deductible for a physical therapy visit provided on June 28, 
2022, by an out-of-network provider.