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

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on August 06, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you do not feel its fair to be 
charged this copayment because you are on a fixed income. 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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for an ambulance ride. 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 an ambulance ride 
provided on August 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat right L4-L5 lumbar transforaminal epidural 
steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not indicated. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the previous injection did not provide at least 50% of sustained improvement in pain 
relief and/or improvement in function. Per the reviewed documentation, the previous injection: 07/14/2022 
Right L4/5 transforaminal epidural steroid injection (TFESI) 2 weeks of greater than 50% pain relief. The 
review has determined that the enrollee does not meet the coverage criteria indicated for this injection. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat right L4-L5 lumbar transforaminal epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mechanical traction therapy (97012), office visit (99202), 
chiropractic manipulative treatment (98940), therapeutic exercises (97110), x-ray exam of the lumbar spine 
(72100), and the extraspinal chiropractic manipulative treatment (98943) rendered by the out-of-network 
(OON) provider from June 22, 2022, through June 27, 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 were rendered by an out-of-
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the mechanical traction therapy (97012), office visit (99202), chiropractic 
manipulative treatment (98940), therapeutic exercises (97110), x-ray exam of the lumbar spine (72100), and 
the extraspinal chiropractic manipulative treatment (98943) rendered by the out-of-network (OON) provider 
from June 22, 2022, through June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the folding walker provided on July 14, 
2022. 
 
You asked the Plan to waive the deductible for the folding walker. You say that you took the walker home but 
have not used 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 $800 
deductible for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay a $800 deductible for the folding walker. This item/service falls within the durable 
medical equipment (DME) and related 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 
deductible for the folding walker provided on July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on August 04, 2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you did not go to the lab on this date, 
only the 2nd. 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 $5 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $5 copayment for lab services. 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. Medical records that were provided show that you were present 
on both dates of service. Therefore, we decided that the Plan does not have to waive the copayment for lab 
services provided on August 04, 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 August 11, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the service should be covered. 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 dates of service February 8, 2022, and 
February 28, 2022. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120) provided on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on August 24, 2022. 
 
You asked the Plan to pay for the subsequent nursing care. You say that medical records were submitted to 
support medical necessity. 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 August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatments provided on 
June 16, 2022 and June 28, 2022. 
 
You asked the Plan to issue reimbursement 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 you do not meet 
criteria for coverage of the acupuncture services provided. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services provided have not been met. Specifically, the acupuncture services in this case were 
not rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Additionally, the acupuncture services were not rendered on the basis of a diagnosis for chronic low 
back pain. Therefore, we decided that the Plan does not have to issue reimbursement for the acupuncture 
treatments provided on June 16, 2022 and June 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided to the enrollee on January 
13, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare does not cover service that are not performed by a Medicare-certified 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program.  
 
The rendering provider is not eligible to bill Medicare. The plan did not pre-approve the services. We found no 
exception that would require the plan to pay for these items/services. 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 emergency room services provided to the enrollee on January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), a panoramic 
radiographic image (D0330), a filling (D2330), and does not have to pay for a complete series of radiographic 
images (D0210) provided from August 11, 2022, through August 18, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you want the Plan to pay. 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. Your benefit for the complete series of 
radiographic images 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.  
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. 
Additionally, the record shows your benefit for the complete series of radiographic images was exhausted on 
date of service August 11, 2022. Therefore, we decided that the Plan does not have to pay more for a 
comprehensive oral evaluation (D0150), a panoramic radiographic image (D0330), a filling (D2330), and does 
not have to pay for a complete series of radiographic images (D0210) provided from August 11, 2022, through 
August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve harvest of bone for use in autogenous grafting 
procedure (D7295) for tooth number 20. 
 
You asked the Plan to pre-approve harvest of bone for use in autogenous grafting procedure (D7295) for tooth 
number 20. You say that you need this service, because the doctor says that he will not proceed to extract the 
tooth. The Plan denied your request. The Plan says this service is not covered under the member's benefit 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 pre-approve 
harvest of bone for use in autogenous grafting procedure (D7295) for tooth number 20.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) and the chiropractic manipulative 
treatment (98940) rendered by the out-of-network (OON) provider from January 19, 2022, through March 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 the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services.  Therefore, we decided that the Plan does not have to pay for the office visit (99202) and the chiropractic 
manipulative treatment (98940) rendered by the out-of-network (OON) provider from January 19, 2022, 
through March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261 x 2) purchased on 
February 9, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items are not payable as they 
were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan contract states that hearing aids must be 
purchased from the Plans select hearing aid provider. Hearing aids purchased outside of the Plans network are 
not covered. The hearing aids in this case were purchased from an out-of-network provider. Therefore, we 
decided that the Plan does not have to issue reimbursement for the hearing aids (V5261 x 2) purchased on 
February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), intraoral 
periapical radiographic images (D0230 x2), full mouth debridement (D4355), and gingival irrigation (D4921 
x4) provided from July 6, 2022, through July 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the charges. The 
Plan denied your request. The Plan says your benefit for the panoramic radiographic image and the intraoral 
periapical radiographic image has already been exhausted. The full mouth debridement and the gingival 
irrigation are not covered services. 
 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 intraoral periapical radiographic image was exhausted on date of service July 6, 
2022, and your benefit for the panoramic radiographic image was exhausted on February 7, 2019. Additionally, 
full mouth debridement and gingival irrigation are not covered services. Therefore, we decided that the Plan 
does not have to pay for a panoramic radiographic image (D0330), intraoral periapical radiographic images 
(D0230 x2), full mouth debridement (D4355), and gingival irrigation (D4921 x4) provided from July 6, 2022, 
through July 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care office visit provided on 
September 23, 2022. 
 
You asked the Plan to waive the copayment for a primary care office visit. You say that the clerk told you that 
you did not have a 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for a primary care office visit. This item/service falls within the 
physician/practitioner services, including doctors 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 copayment for a primary care office visit provided on September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided 
on August 26, 2022. 
 
You asked the Plan to pay for a complete series of radiographic images. You say that you should not have to 
pay for this service. The Plan denied your request. The Plan says the service at issue 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 pay for a 
complete series of radiographic images (D0210) provided on August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic comprehensive preventive medicine reevaluation 
provided on August 01, 2022. 
 
You asked the Plan to pay for periodic comprehensive preventive medicine reevaluation. You say that you are 
requesting reconsideration for the denied claim and would like claim to be reprocessed with payment. You say 
that you have provided the referral form, medical records, and waiver of liability for review. 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 periodic comprehensive 
preventive medicine reevaluation provided on August 01, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is a medical necessity for you. The Plan 
denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in 
a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and intraoral periapical 
radiographic images (D0230) provided on September 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were necessary, and you want the 
Plan to pay. The Plan denied your request. The Plan says your benefits for the requested services have 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 benefits for the requested services were exhausted on date of service August 31, 2022. Therefore, 
we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and intraoral periapical 
radiographic images (D0230) provided on September 22, 2022.