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

 
We decided that the Plan does not have to pre-approve a left knee arthroscopy. 
 
You asked the Plan to pre-approve the requested services. You say that you are in extreme pain. The Plan 
denied your request. The Plan says conservative treatment has not been demonstrated. 
 
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 requested services. Our physician 
reviewer found that you presented with left knee pain rated at 4 out of 10. Conservative treatment included a 
brace, compression, elevation, ice, daily exercise, massage, and medications. There has not been a trial and 
failure of recent, reasonable, comprehensive less invasive conservative care measures. There are limited large-
scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested left knee arthroscopy, in this case, is not medically 
reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left knee arthroscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 October 24, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection of laboratory specimens provided on September 2, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for collection of laboratory specimens. You say that the reports attached support the 
services provided. The Plan denied your request. The Plan says there is no authorization on file prior to the 
services rendered. 
 
 
 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 collection of laboratory specimens provided on 
September 2, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on May 18, 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 May 21, 2021. Therefore, 
we decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on May 18, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), extraspinal chiropractic manipulative 
treatment (98943), manual therapy (97140), hot or cold packs therapy (97010), therapeutic exercises (97110), 
ultrasound therapy (97035), and the neuromuscular reeducation (97112) provided on August 4, 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 a covered benefit. 
 
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 office visit (99202), extraspinal chiropractic manipulative treatment 
(98943), manual therapy (97140), hot or cold packs therapy (97010), therapeutic exercises (97110), ultrasound 
therapy (97035), and the neuromuscular reeducation (97112) provided on August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient clinic visit provided on August 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient clinic visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
rendered. 
 
 
 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 an outpatient clinic visit provided on August 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 the dental services on September 
26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-ray, cone beam 
computed tomography (CT) scan, and an adjunctive pre-diagnostic test (D0150, D0210, D0367, D0431) 
provided on September 19, 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 comprehensive oral evaluation 
and intraoral x-ray had already been exhausted. Coverage for the cone beam CT scan and adjunctive pre-
diagnostic test 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 2, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-ray, 
cone beam computed tomography (CT) scan, and an adjunctive pre-diagnostic test (D0150, D0210, D0367, 
D0431) provided on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite, periodontal scaling and root 
planing, maxillary partial denture, and tooth extraction (D5213, D4342, D7210, D2392) provided on January 
19, 2022, to September 6, 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 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 resin-
based composite, periodontal scaling and root planing, maxillary partial denture, and tooth extraction (D5213, 
D4342, D7210, D2392) provided on January 19, 2022, to September 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 11, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you called 
the ambulance due to a medical emergency. You also say that you denied being transported to the emergency 
room where you had a previous bad experience. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 11, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed for date of service March 15, 2021. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed codes cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. There are no medical records or a requisition form from the 
enrollees treating physician to show that the testing was medically necessary. The file shows that the Plan 
made multiple attempts to obtain additional information without success. Based on this information, we 
decided the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the drug testing billed for date of service March 15, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 14, 2022. 
 
You asked the Plan to pay for office 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 office visit provided on 
April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing services (D4341) 
provided on October 17, 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 May 23, 2022 and 
August 22, 2022. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root 
planing services (D4341) provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that a primary care physician (PCP) referral was not 
required. You say you are in-network and would like the claim reprocessed. The Plan denied your request. The 
Plan says the provider is not a network provider, and the service was not referred by a network provider or 
rendered in an in-network facility. 
 
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 
office visit. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on August 23, 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 
1, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with 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 (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $75 copayment for ambulance services.  
 
The enrollee has been asked to pay a $75 copayment for ambulance services. However, you are only being 
asked to $238.54 which is less than the required amount. This item/service falls within the ambulance services 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on 
September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided on 
September 1, 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 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 
periodontal scaling and root planing (D4342) provided on September 1, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on August 16, 2022. 
 
You asked the Plan to pay for inpatient hospital services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says that this service does not meet the coverage requirements 
in the applicable Local Coverage Determination (LCD) or National Coverage Determination (NCD). 
 
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. the Plan's denial reason is that criteria for coverage were not met. However, the 
Plan failed to provide any medical records or evidence of having made reasonable attempts to obtain medical 
records. There is no way to evaluate the Plan's denial reason without any medical records. Therefore, we 
decided that the Plan has to pay for inpatient hospital services provided on August 16, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 1, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $310 
copayment for ambulance services.  
 
You have been asked to pay a $310 copayment for ambulance services. This item/service falls 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 October 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on May 3, 2022, to May 
31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the services rendered are not covered by an out-of-
network (OON) 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 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 physical therapy services provided on May 3, 
2022, to May 31, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the upper gastrointestinal tract (74240) and x-ray 
of the swallowing function (74230) provided on August 30, 2022. 
 
  You asked the Plan to pay for the x-ray of the upper gastrointestinal tract and x-ray of the swallowing function. 
You say that the enrollee was consulted in a skilled nursing facility, and you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says the documentation supports the studies represented 
were performed at a nursing home (via mobile van/portable x-ray), which are denied as an excluded place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures and examinations which are not 
covered under the portable x-ray provision include procedures involving fluoroscopy and procedures involving 
the use of contrast media. 
 
We looked at the file and Medicare rules. Specifically, we find that a barium swallow study was provided in the 
portable mobile radiology setting. This imaging requires both the use of fluoroscopy and contrast, which are 
not covered under the portable x-ray provision. Based on this information, we decided that Medicare rules for 
coverage of the x-ray of the upper gastrointestinal tract and x-ray of the swallowing function have not been 
met. Therefore, we decided that the Plan does not have to pay for the x-ray of the upper gastrointestinal tract 
(74240) and x-ray of the swallowing function (74230) provided on August 30, 2022.