Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for core buildup, including any pins when required 
(D2950), and crown - porcelain/ceramic (D2740) provided on July 28, 2022. 
 
You asked the Plan to pay more for the core-build up and crown - porcelain/ceramic. You say that you called 
your dentist and found out that the dentist placed a crown on #19 for $2,064. You also say that you are seeking 
approval to see if the Plan can cover more of the cost. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
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 core buildup, including any pins 
when required (D2950) are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for core buildup, including any pins when required (D2950). 
 
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 75% 
coinsurance for crowns provided out-of-network.  
 
You have been asked to pay a 75% coinsurance for the core-build up and crown - porcelain/ceramic. This 
service falls within the crowns provided out-of-network 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 pay 
more for core buildup, including any pins when required (D2950), and crown - porcelain/ceramic (D2740) 
provided on July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on October 25, 2022, to October 
31, 2022. 
 
You asked the Plan to pay for oxygen equipment. You say that you needed these items because your previous 
equipment was broken. 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 oxygen equipment 
provided on October 25, 2022, to October 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) of abdomen and pelvis with 
contrast material (74177) provided on May 04, 2022. 
 
You asked the Plan to pay for the CT. You say that the claim was coded correctly. The Plan denied your 
request. The Plan says the diagnosis code does not match the gender of the patient. If the patient is transgender 
a specific modifier would need to be used.   
 
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly.  
 
We looked at the file and Medicare rules. Specifically, the documentation indicates that the enrollee is male. 
The claim includes diagnosis code D25.9 referring to leiomyoma of the uterus. Of note, CPT code 74177 has 
not been billed with the required modifier to indicate that the enrollee is transgender. Based on this 
information, we decided that Medicare rules for coverage of the CT have not been met. Therefore, we decided 
that the Plan does not have to pay for a computed tomography (CT) of abdomen and pelvis with contrast 
material (74177) provided on May 04, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc. 
 You asked the Plan to pre-approve Genvisc. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Genvisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not outline 
contraindications or reasons these medications were not considered or that the plans additional required drug 
would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the 
documentation, Genvisc is not approved as step criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Genvisc.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 7, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
needed help through 911 and do not believe this claim should be denied since there were no other solutions 
available. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 7, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on October 7, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the medical services provided on April 21, 2022. 
 
You asked the Plan to pay for the medical services. You say that these procedures were considered reasonable 
and necessary at the time of service. You also say that emergency department services are not subject to pre-
authorization requirements, and the enrollee presented at the emergency room with weakness and altered 
mental status, requiring care. The Plan denied your request. The Plan says that these services were not 
authorized. 
 
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 records do not support the Plans denial in this case. The Plan did not 
provide a copy of the applicable 2022 Schedule of Cost Sharing for this case. Without this information we 
cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee 
has been adequately notified of the Plan's coverage rules and benefits. This means that the Plan has not 
provided a valid reason for denying payment of the medical services. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pay for the medical services provided on April 21, 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 pay for subsequent nursing facility care visits provided on November 
02, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that it is the responsibility of the 
facility 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 subsequent nursing 
facility care visits provided on November 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower dentures (D5140). 
 
You asked the Plan to pre-approve the dental services. You say that this 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 date of service April 9, 2021. Therefore, 
we decided that the Plan does not have to pre-approve lower dentures (D5140).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on October 17, 2022, billed with 
procedure codes 99204, 74230, 720400, 70100, 70310, 71045, and 74240. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the wrong place of service code was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, 
they are often provided to serve an entity for which another Place of Service (POS) code exists.  
 We looked at the file and Medicare rules. Place of service 11 was billed, however the documentation does not 
support that the services were done in an office setting. Based on this information, we decided that Medicare 
rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have 
to pay for medical services provided on October 17, 2022, billed with procedure codes 99204, 74230, 720400, 
70100, 70310, 71045, and 74240.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial upper and lower dentures (D5213, D5214). 
 
You asked the Plan to pre-approve the dental services. You say that this 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 date of service September 23, 2019. 
Therefore, we decided that the Plan does not have to pre-approve partial upper and lower dentures (D5213, 
D5214).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of pelvis to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an MRI of pelvis. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested provider is out-of-network. This service is available by a provider in 
the network. 
 
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 
magnetic resonance imaging (MRI) of pelvis to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 15, 2022. 
 
You asked the Plan to pay for an office visit. You say that this service was medically necessary. 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 September 15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on August 23, 2022, to August 31, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you are not liable 
for a copayment for the PT services. 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 outpatient rehabilitation service. 
 
You have been asked to pay a $35 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation service 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. The total you owe is $105 for a PT services ($35 per visit x 3 visits = $105). 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit 
provided on August 23, 2022, to August 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93312 billed for date of service November 
28, 2022. 
 You asked the Plan to pay for procedure code 93312. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 93312 is bundled into payment for code 00541. 
 
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, we have confirmed that code 93312 
is a column II code to column I code 00541. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93312 billed for date of service November 28, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the impact resistant lens, the single eyeglass lens, the 
anti-reflective coating, and the eyeglass frames on claim one and the anti-reflective coating, the eyeglass 
frames, the impact resistant lens, and the single eyeglass lens on claim two provided on December 26, 2022. 
 
You asked the Plan to pay more for the vision items. You say that you were advised by the provider that you 
would pay $0 for both pairs of glasses. The Plan denied your request. The Plan says the benefits have been 
exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $150 allowance once a year and one pair of eyeglasses every 
year. 
 
We looked at the file and the Plan's rules. Specifically, for the first claim, the Plan applied the $150 allowance 
to the retail price of the eyeglasses. Also, for claim 2, the benefit had been exhausted on December 26, 2022, 
with the purchase of the first pair of eyeglasses. Based on this information, we decided that the Plan's rules for 
coverage of the vision items have not been met. Therefore, we decided that the Plan does not have to pay more 
for the impact resistant lens, the single eyeglass lens, the anti-reflective coating, and the eyeglass frames on 
claim one and the anti-reflective coating, the eyeglass frames, the impact resistant lens, and the single eyeglass 
lens on claim two provided on December 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lung biopsy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a lung biopsy. You say that this is medically necessary. The Plan denied 
your request. The Plan says this provider is out-of-network. This service is available in-network. 
 
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 
a lung biopsy 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 replacement group 3 standard power wheelchair 
(K0856) and accessories (E0705, E0955, E1028, E2300, E2310, E2313, E2361, E2377, E2607, E2620, K0040, 
K0108). 
 
You asked the Plan to pre-approve a replacement power wheelchair and accessories. You say that you disagree 
with the denial and request reconsideration. The Plan denied your request. The Plan says the current wheelchair 
has not reached reasonable useful life, as it is less than five years old. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 
 
 
 
 The file shows that the enrollee was approved and received a power wheelchair on July 27, 2022. The current 
power wheelchair serves the same purpose as a replacement power wheelchair and accessories. The records 
show that there is no documentation that the current wheelchair is damaged or not functioning properly and the 
wheelchair is less than five years old. Therefore, we decided that the Plan does not have to pre-approve a 
replacement group 3 standard power wheelchair (K0856) and accessories (E0705, E0955, E1028, E2300, 
E2310, E2313, E2361, E2377, E2607, E2620, K0040, K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on November 01, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting the submitted documentation be 
reviewed. 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 lab testing provided on 
November 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on October 24, 2022. 
 
You asked the Plan to pay for rest home visit. You say that you were not able to verify eligibility and 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 rest home visit provided 
on October 24, 2022.