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

 
We decided that the Plan does not have to pay for a rhumatology visit provided on August 29, 2022. 
 
You asked the Plan to pay for a rhumatology visit. You say that the Plan told you that this provider was in 
network, but they werent. You feel the plan should cover this. 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 a rhumatology visit 
provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on June 03, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that we depend upon the facility staff to verify 
eligibility and to obtain authorization. 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 a nursing facility visit 
provided on June 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2330) for tooth #11 and to pay 
more for the resin-based composite (D2330) for tooth #6 and #9 provided by on August 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the denied services should not be denied and 
should be paid. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. Also, you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of August 3, 2022. 
You have also been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay for the resin-based composite (D2330) for tooth #11 
and to pay more for the resin-based composite (D2330) for tooth #6 and #9 provided by on August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on September 
20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the claim on August 15, 2022, was counted as 
an oral evaluation, but it was a recheck of an implant so that you could be released from his care. 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 March 15, 2022, and on 
August 15, 2022. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120) provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic services and supplies provided on 
June 29, 2022. 
 
You asked the Plan to waive the coinsurance for diabetic services and supplies. You say that you disagree with 
the coinsurance. 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 diabetic services and supplies.  
 
You have been asked to pay a 20% coinsurance for diabetic services and supplies. The total allowed amount for 
the diabetic supplies is $531.01. The amount you are being asked to pay is $106.20 ($531.01 x 20% = 
$106.20). This item/service falls within the diabetic 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 coinsurance for diabetic services and supplies provided on June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oncology visit provided on September 06, 2022. 
 
You asked the Plan to pay for an oncology visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an oncology visit 
provided on September 06, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on May 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for emergency room services. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says our plan covers worldwide emergency and urgent care services outside 
of the United States under the following circumstances. If the enrollee has an emergency or an urgent need for 
care outside of the U.S. and its territories, they will be responsible to pay for those services upfront and request 
appropriate reimbursement from us. We will reimburse the enrollee, for covered out-of-network emergency and 
urgent care services outside of the U.S. and its territories, at rates no greater than the rates at which Original 
Medicare would pay for such services had the services been performed in the United States in the locality 
where you reside. 
 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 emergency room services provided on May 28, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554) and supply allowance for therapeutic continuous glucose monitor 
(CGM), includes all supplies and accessories (K0553). 
 
You asked the Plan to pre-approve the CGM device and supplies. You say that the previous prior authorization 
was approved for the FreeStyle sensor, and you feel this prior authorization should be approved as well. The 
Plan denied your request. The Plan says there has not been any additional clinical notes submitted to support 
medical necessity of the requested diabetic supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the CGM device and supplies have been met. per the records submitted, the provider has not provided clinical information to support the medical 
necessity of the requested diabetic supplies. Therefore, we decided that the Plan does not have to pre-approve a 
receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (K0554) and supply 
allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories (K0553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services (D0150, D1110, D1206) provided on 
September 1, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from 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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services (D0150, D1110, D1206) 
provided on September 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy visit provided on August 19, 2022. 
 
You asked the Plan to pay for a physical therapy visit. You say that this was medically necessary and should be 
covered. 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 a physical therapy visit 
provided on August 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on September 13, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service 
because you followed the advice of the dentist on what was needed. The Plan denied your request. The Plan 
says the denial of payment for this service is correct, because the consultation is not covered by the 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. 
 
  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 
consultation (D9310) provided on September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #21. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the x-rays the dentist sent show a crown is not needed to fix the 
enrollee's tooth. 
 
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 dental 
service when the services are medically necessary and reasonable.  
 
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 dental service. Our reviewer says 
that the crown for tooth #21 is not medically necessary. Our physician reviewer found that the documentation 
provided does not meet the criteria for coverage for a crown restoration (D2750) for tooth #21. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2750) for tooth #21.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the cost sharing for an MRI provided on November 22, 2021. 
 
You asked the Plan to waive the cost sharing for an MRI. You say that you were told by Plan representatives 
that there would only be a $180 copayment. The Plan denied your request. The Plan says that the cost sharing 
has been applied correctly. 
 
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 has not shown that the claim at issue is a separate and distinct service 
than the claim the cost sharing was applied to in the provided breakdown. Therefore, we decided that the Plan 
has to waive the cost sharing for an MRI provided on November 22, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown on tooth #10 and 27 (D2752) and 
periodontal scaling and root planing on the upper right and upper left quadrants (D4341). 
 
You asked the Plan to pre-approve crowns and periodontal scaling. You say that the dentist already made his 
teeth smaller for the crowns. The Plan denied your request. The Plan says that the teeth do not appear to have 
significant breakdown due to decay or trauma to require crowns. The Plan also says that a minimum of four 
affected teeth need to be present in the quadrant to qualify for periodontal scaling. 
 
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 crowns and 
periodontal scaling when the services are medically necessary and reasonable.  
 
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 crowns and periodontal scaling. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that a review of the documentation indicates that tooth #10 has a crown in place which appears adequate. There was no indication 
as to why the crown needs replacing. Tooth #27 does not appear to have significant coronal breakdown due to 
caries or fracture to warrant a crown restoration. Periodontal scaling and root planing the maxillary right and 
left quadrants does not meet the criteria for coverage since there does not appear to be four or more teeth in the 
maxillary right and left quadrants. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crowns and periodontal scaling have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a porcelain crown on tooth #10 and 27 (D2752) and periodontal scaling 
and root planing on the upper right and upper left quadrants (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA) (64624). 
 
You asked the Plan to pre-approve genicular RFA. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested service is experimental and not medically 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 genicular RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational and not 
medically necessary for the treatment of chronic knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular radiofrequency ablation (RFA) (64624).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on August 
12, 2022. 
 
You asked the Plan to waive the copayment for emergency room visit. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency room visit. This item/service falls within the 
emergency 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 emergency room visit 
provided on August 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face down recovery chair, provided on July 26, 2022. 
 
You asked the Plan to pay for the face down recovery chair. You say that the item should be covered. The Plan 
denied your request. The Plan says this provider does not participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the face down recovery chair, provided 
on July 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that that you need additional physical therapy 
visits due to your fall that you had. You say that physical therapy will help you get better. The Plan denied your 
request. The Plan says 6 additional physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have chronic back pain which does not meet the coverage 
criteria for the additional physical therapy visit. Additional visits are not medically necessary for a chronic 
condition and are not reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 6 additional physical therapy visits.