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

 
We decided that the Plan does not have to pay for laboratory services provided on December 05, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. 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 laboratory services 
provided on December 05, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) calcium scoring. 
 
You asked the Plan to pre-approve CT calcium scoring. You say that this can circumvent a more serious health 
problem. The Plan denied your request. The Plan says this scan is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring by CT scan is not 
covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CT calcium scoring have not been met. Therefore, we decided that the Plan does not have to pre-
approve computed tomography (CT) calcium scoring.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain fused to high noble metal (D6240) 
Tooth #5, 7, 8, 9, 10 and retainer crown - porcelain fused to high noble metal (D6750) Tooth #13. 
 
You asked the Plan to pre-approve the dental services. You say that you need the requested services. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes the 
requested pontic - porcelain fused to high noble metal (D6240) and retainer crown - porcelain fused to high 
noble metal (D6750) but is limited up to four units fixed dentures per year, covered one per tooth per life. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you have been pre-approved for retainer crown - porcelain fused to high noble metal (D6750) Tooth #4, 
6, 11, 12; therefore, this benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve pontic - porcelain fused to high noble metal (D6240) Tooth #5, 7, 8, 9, 10 and retainer crown - 
porcelain fused to high noble metal (D6750) Tooth #13.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen with 
contrast. 
 
You asked the Plan to pre-approve a computed tomography (CT) scan of the abdomen with contrast. You say 
that a repeat CT scan of the abdomen has been requested for medical necessity for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not meet clinical criteria because there is not enough proof 
for repeated special imaging currently for the mass (growth) in the stomach (pancreas). 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 computed tomography (CT) scan of 
the abdomen with contrast. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found hyperuricemia is not demonstrated in the records and requested imaging appears to be only of 
academic value. 
 
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 computed tomography (CT) scan abdomen with contrast have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
abdomen with contrast.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 14, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are appealing based on medical necessity and 
the records 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 an office visit provided 
on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional pontics and a crown (D6240, D2710). 
 
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 your benefit for the requested item or 
service has already been exhausted. The crowns 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 with the Plans prior authorization. 
Therefore, we decided that the Plan does not have to pre-approve 4 additional pontics and a crown (D6240, 
D2710).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for out-of-network diabetes screening provided 
on September 1, 2022. 
 
You asked the Plan to waive the cost share for out-of-network diabetes screening. You say that you disagree 
with the cost share. 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 $1,000 deductible which applies to out-of-network diabetes screening.  
 
The item or service you asked the Plan to waive the cost share for falls within the out-of-network diabetes 
screening benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $1,000 deductible which applies to out-of-network diabetes screening. You are being asked to pay $190.24 
towards your $1,000 deductible. This cost sharing is a contractual obligation that had not been met at the time 
out-of-network diabetes screening was received on September 1, 2022. Therefore, we decided that the Plan 
does not have to waive the cost share for out-of-network diabetes screening provided on September 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the goniotomy and the cataract surgery 
provided on July 20, 2022.  
 
You asked the Plan to waive the coinsurance for the goniotomy and the cataract surgery. You say that you had 
already paid a copay and you should not have to pay the extra. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Medicare-covered surgery at an ambulatory surgical center.  
 
You have been asked to pay $425.90 coinsurance, which is 20% of the allowed amount for the goniotomy ($2,129.50 allowed amount x 20% = $425.90). You have also been asked to pay $118.03 coinsurance, which is 
20% of the allowed amount for the cataract surgery ($590.14 allowed amount x 20% =$118.03).  These 
items/services fall within the outpatient surgery and other medical services provided in an ambulatory surgical 
center benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the goniotomy and the cataract 
surgery provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 27, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you did not order this service and 
should not have to pay for 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 $150 
copayment for outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $150 copayment for the ultrasound. This item/service falls within the outpatient 
diagnostic tests, including ultrasounds benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the ultrasound provided on October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator and the portable 
oxygen system provided on December 15, 2022. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator and the portable oxygen system. You 
say that you have not used the equipment and should not be charged. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network durable medical equipment.  
 
You have been asked to pay $15.53 coinsurance, which is 20% of the allowed amount for the oxygen 
concentrator ($77.63 allowed amount x 20% = $15.53). You have also been asked to pay $3.46 coinsurance, which is 20% of the allowed amount for the portable oxygen system ($17.29 allowed amount x 20% = $3.46). 
These items/services fall within the durable medical equipment 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 coinsurance for the oxygen concentrator and the portable oxygen system 
provided on December 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
October 14, 2022, to October 18, 2022 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not think you 
should have to pay since this was the result of a previous procedure. 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 $250 
copayment per day for days 1-5 of each inpatient hospital stay.  You have been asked to pay a $250 copayment per day for days 1-4 of the inpatient hospital stay. You have not 
been charged for the day you were discharged. You have been asked to pay a total of $1,000 ($250 copayment 
per day x 4 days = $1,000). This item/service falls within the inpatient hospital 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 the inpatient hospital stay provided from October 14, 2022, 
to October 18, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
tooth #'s 20 and 29  (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that your dentist is recommending the implant 
procedures. The Plan denied your request. The Plan says your benefit for the requested service has already been 
exhausted as only two (2) implant services can be approved, and they are already approved for tooth #s 30 and 
19. 
 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 service was exhausted on date of service January 31, 2023. Therefore, we 
decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant tooth 
#'s 20 and 29  (D6010).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an outpatient surgery and a prosthetic device 
provided on August 2, 2022. 
 
You asked the Plan to waive the cost share for an outpatient surgery and a prosthetic device. You say that you 
disagree with the cost share. 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 $150 
copayment for outpatient surgery/Medicare-covered services provided in an ambulatory surgical center and a 
20% coinsurance for prosthetic devices and related supplies.   
You have been asked to pay a $150 copayment for an outpatient surgery and a 20% coinsurance for a prosthetic 
device. The total allowed amount for the prosthetic device is $1,226.80. You are being asked to pay $245.36 
($1,226.80 x 20% = $245.36). The total amount you are being asked to pay is $395.36 ($150 + $245.36 = 
$395.36). This item/service falls within the outpatient surgery/Medicare-covered services provided in an 
ambulatory surgical center and prosthetic devices 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 cost share for an outpatient surgery and a prosthetic device provided on August 2, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
November 19, 2022, to November 25, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were given poor 
care which prolonged your stay in the hospital. 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 $160 
copayment per day for days 1-10 of each in-network inpatient hospital stay.  You have been asked to pay a $160 copayment per day for days 1-5 of the inpatient hospital stay. You have not 
been charged for the day you were discharged. You have been asked to pay a total of $800 ($160 copayment 
per day x 5 days = $800). This item/service falls within the inpatient hospital 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 the inpatient hospital stay provided from November 19, 2022, to 
November 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance services provided from 
August 17, 2022, to November 5, 2022. 
 
You asked the Plan to waive the copayments for the ambulance services. You say that the town provides these 
ambulance services for free. 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 $250 
copayment for each one-way ambulance service.  
 
You have been asked to pay up to a $250 copayment for each ambulance service. These items/services fall 
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 copayments for the 
ambulance services provided from August 17, 2022, to November 5, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve white glass with metal crown (D2751) Tooth #29. 
 
You asked the Plan to pre-approve dental services. You say that your crown is broken, and you need to have a 
new one put on. The Plan denied your request. The Plan says that they did not receive x-rays to be able to make 
the determination if the crown is medically necessary. 
 
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. Specially, the plan did not send us medical records. Without medical records, we 
cannot determine whether or not the requested service is medically necessary. Therefore, we decided that the 
Plan has to pre-approve white glass with metal crown (D2751) Tooth #29.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and accessories 
(E0978, E1007, E1012, E1028, E2311, E2313, E2340, E2343, E2361, E2377, E2609, E2617, K0040). 
 
You asked the Plan to pre-approve the power wheelchair and accessories. The Plan denied your request. The 
Plan says that the requested items are not covered if the enrollee resides in a nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
The record shows that the power wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861) and 
accessories (E0978, E1007, E1012, E1028, E2311, E2313, E2340, E2343, E2361, E2377, E2609, E2617, 
K0040).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on July 22, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $350 
copayment for outpatient surgery/hospital or ambulatory surgical center. 
 
You have been asked to pay a $350 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/hospital or ambulatory surgical center 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 outpatient surgery provided on July 22, 2022.