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

 
We decided that the Plan does not have to pay for a specialist visit, a blood test, and collection of a blood 
sample provided on November 28, 2022. 
 
You asked the Plan to pay for a specialist visit, a blood test, and collection of a blood sample. You say that 
these services do not require 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 specialist visit, a blood 
test, and collection of a blood sample provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy or gingivoplasty to allow access for 
restorative procedure, per tooth (D4212). 
 
You asked the Plan to pre-approve the gingivectomy or gingivoplasty. The Plan denied your request. The Plan 
says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for laminectomy, facetectomy and foraminotomy rendered on October 25, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 63048 is "Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of 
spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; 
each additional vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary 
procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure details cite the 
ligamentum flavum was released from the undersurface of the lamina. Using a combination of Kerrison 
rongeurs and curettes, the lamina, ligamentum flavum, and lateral recesses were removed. A medial 
facetectomy was performed. A foraminotomy was performed using Kerrison rongeurs. The foramen was 
palpated with the Woodson and it was felt to be adequately decompressed. The bilateral L2-S1 nerve roots 
were decompressed. The records note that a medial facetectomy, laminectomy, and foraminotomy were 
performed with decompression of nerve roots of L2-S1. Therefore, the records do support CPT 63048 in this 
case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
laminectomy, facetectomy and foraminotomy rendered on October 25, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed, with any type side rails, 
with mattress (E0265). 
 
You asked the Plan to pre-approve the hospital bed. You say that you have had Parkinson's disease for 20 years 
and it has made you increasingly weak with worsening mobility problems, now requiring a hospital bed for 
home use. Several home health aides have strongly recommended such a bed. The Plan denied your request. 
The Plan says a total electric hospital bed is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric 
hospital bed, with any type side rails, with mattress (E0265).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cataract surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the cataract surgery. You say that you would like this service to be 
performed out-of-network. The Plan denied your request. The Plan says you must receive your care from a 
network 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the surgical dressings provided from June 
28, 2022, to November 22, 2022. 
 
You asked the Plan to waive the coinsurance for the surgical dressings. You say that you were not informed 
there would be a coinsurance for the items. 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 durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the surgical dressings. These items/services fall within the 
durable medical equipment and related supplies benefit category.  Date of Service Code Allowed 
Amount 
20% 
Coinsurance 
June 28, 2022, to July 27, 2022 A6212 $178.20 $35.64 
June 28, 2022, to July 27, 2022 A6196 $135.20 $27.04 
July 26, 2022, to August 9. 2022 A6219 $8.80 $1.76 
July 26, 2022, to August 9. 2022 A6196 $67.60 $13.52 
August 10, 2022, August 24, 2022 A6219 $4.40 $0.88 
August 10, 2022, August 24, 2022 A6196 $33.80 $6.76 
September 16, 2022, to September 30, 2022 A6196 $67.60 $13.52 
September 16, 2022, to September 30, 2022 A6021 $192.90 $38.58 
September 16, 2022, to September 30, 2022 A6219 $8.80 $1.76 
November 22, 2022 A6210 $109.74 $21.95 
November 22, 2022 A6212 $53.46 $10.69 
November 22, 2022 A6219 $4.40 $0.88 
 
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 surgical dressings provided from June 28, 2022, to 
November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive periodontal evaluation - new or 
established patient (D0180) and cone beam CT capture and interpretation with limited field of view - less than 
one whole jaw (D0364). 

You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of services. 
The Plan denied your request. The Plan says these services are not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Comprehensive periodontal 
evaluation - new or established patient (D0180) and cone beam CT capture and interpretation with limited field 
of view - less than one whole jaw (D0364) are not covered under the Plan's dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0180 and D0364 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive periodontal evaluation - new or established patient (D0180) and cone beam CT capture and 
interpretation with limited field of view - less than one whole jaw (D0364).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit and blood flow 
ultrasound provided on January 4, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit and ultrasound. You say that you 
already paid for the office visit and should not have additional 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 $35 
copayment for each specialist office visit. Your contract with the Plans also clearly says that you must pay a $35 copayment for each diagnostic procedure or test, including ultrasounds. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay a $35 copayment for the 
ultrasound. This item/service falls within the outpatient diagnostic tests and therapeutic services benefit 
category. You have been asked to pay a total of $70 ($35 copayment + $35 copayment = $70). 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 specialist office visit and blood flow ultrasound provided on 
January 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on November 7, 2022. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the radiology services provided have not been met. The procedure is a barium swallow study, and 
this means that it involves the administration of a substance to the enrollee. Therefore, we decided that the Plan 
does not have to pay for radiological services provided on November 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cystourethroscopy provided on September 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the cystourethroscopy. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says 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 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 a cystourethroscopy provided on September 2, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the specialist visit. You say that the enrollee would like to see this out-of-
network provider. The Plan denied your request. The Plan says enrollees must receive their care from a 
network 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the specialist visit to be provided 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 continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that you are appealing the denied 
CGM. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
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 and related supplies have 
been met. Specifically, there was no medical documentation submitted to confirm if the Medicare coverage 
criteria for the CGM was met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and related supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an angiogram, endovascular revascularization services, and 
an intravascular ultrasound provided on October 26, 2022. 
 
You asked the Plan to pay for an angiogram, endovascular revascularization services, and an intravascular 
ultrasound. You say that these services were authorized. 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 angiogram, 
endovascular revascularization services, and an intravascular ultrasound provided on October 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires another 3 to 4 
weeks to continue weaning oxygen and to transition from their acute illness. The Plan denied your request. The 
Plan says an LTACH admission is not medically necessary, and the enrollee's needs can be met in another 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
   
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the drug injections and drug administration 
provided from March 2, 2022, to April 8, 2022. 
 
You asked the Plan to waive the cost share for the drug injections and drug administration. You say that you 
had already met your out-of-pocket maximum for the year. 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 Part B drugs. Your contract with the Plan also clearly says that you must 
pay a $375 copayment for in-network surgical or other services provided at an outpatient hospital.  
 
The records show that your maximum out-of-pocket was not met at the time these services were received. You 
have been asked to pay 20% coinsurance for each drug injection. These items/services fall within the in-
network Medicare Part B drugs benefit category. You have also been asked to pay up to a $375 copayment for 
each drug administration service. These items/services fall within the outpatient surgery benefit category. 
 
Date CPT Allowed Amount Copay Coinsurance 
March 2, 2022 96413 $328.38 - $65.68 
March 2, 2022 96417 $63.85 - $12.77 
March 2, 2022 96375 $41.21 $41.21 - 
March 4, 2022 96361 $41.21 $41.21 - 
March 4, 2022 96374 $210.69 $210.69 - 
March 7, 2022 96360 $210.69 $210.69 - 
March 7, 2022 96361 $41.21 $41.21 - 
March 16, 2022 96413 $328.38 - $65.68 
March 16, 2022 96417 $63.85 - $12.77 
March 16, 2022 96375 $41.21 $41.21 - 
March 18, 2022 96361 $41.21 $41.21 - 
March 18, 2022 96374 $210.69 $210.69 - 
March 30, 2022 96413 $328.38 - $65.68 
March 30, 2022 96417 $63.85 - $12.77 
March 30, 2022 96375 $41.21 $41.21 - 
April 6, 2022 96413 $328.38 - $65.68 
April 6, 2022 96417 $63.85 - $12.77 
April 8, 2022 96361 $41.21 $41.21 - 
April 8, 2022 96374 $210.69 $210.69 - 
Total   $1,131.23 $313.80 
Grand Total   $1,445.03 
 
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 the drug injections and drug administration provided from 
March 2, 2022, to April 8, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Part B injectable services provided on June 14, 2022. 
 
You asked the Plan to pay for the Part B injectable services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that they were unable to make a 
determination with the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, we find that the Plan has not provided enough evidence to support 
the denial of payment for the services provided based on Medicare criteria. There is no evidence of a duplicate 
claim having been submitted and paid for. Therefore, we decided that the Plan has to pay for the Part B 
injectable services provided on June 14, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care office visit provided on 
October 10, 2022. 
 
You asked the Plan to reduce the copayment for the urgent care office visit. You say that you think this 
copayment should be $10. 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 $30 
copayment for urgently needed services. 
 
You have been asked to pay a $30 copayment for the urgent care office visit. This item/service falls within the 
urgently needed 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 reduce the copayment for the urgent 
care office visit provided on October 10, 2022.