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

 
We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental and not covered. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes 
establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS 
system would not be considered medically appropriate and necessary in this patients clinical management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a test socket above knee (L5624) provided 
on October 28, 2021. 
 
You asked the Plan to waive the deductible for the test socket above knee. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the deductible applied 
correctly based on the services provided. 
 
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 $750 deductible which applies to Durable medical equipment (DME) 
and related supplies.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
medical equipment (DME) and related supplies. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $750 deductible which applies to Durable medical equipment (DME) and related 
supplies. This cost sharing is a contractual obligation that had not been met at the time the test socket above 
knee was received on October 28, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for a test socket above knee (L5624) provided on October 28, 2021.  
 
Since the $750 deductible was met, you have also been asked to pay a $10.62 coinsurance. 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.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on November 19, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  
November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adicoectomy anterior (D3410), and a retrograde filling 
(D3430) provided by an out-of-network provider on December 8, 2021. 
 
You asked the Plan to pay for adicoectomy anterior and a retrograde filling. You say that this is medically 
necessary. The Plan denied your request. The Plan says D3410 and D3430 are not covered 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, 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 
adicoectomy anterior (D3410), and a retrograde filling (D3430) provided by an out-of-network provider on 
December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve Freestyle Lite test strips. You say that you do not agree with the denial and 
would like to request reconsideration. The Plan denied your request. The Plan says no additional information 
was provided regarding the plans preferred diabetic testing supplies. The Plan also says the requested product 
is not on your plan's preferred glucose monitoring test strip. 
 
 
 
 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 Freestyle Lite test strips have been 
met. Specifically, the documentation submitted does not include any clinical information to verify that you 
have tried and failed the Plan's preferred brands or that the Plan's preferred brands would be contraindicated for 
you. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), panoramic x-ray 
(D0330), periapical x-rays (D0220, D0230 x 4), simple extractions (D7140 x 2), and surgical extraction 
(D7210) provided on December 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that you understand that your plan does not cover 
routine dental charges. You also say that you thought that the surgical cost of $180 should be covered. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation 
(D0140), panoramic x-ray (D0330), periapical x-rays (D0220, D0230 x 4), simple extractions (D7140 x 2), and 
surgical extraction (D7210) provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 16, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that an authorization is not required, and you would like 
the claim reprocessed for payment. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 an office visit provided on February 16, 2022, by 
an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on January 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the duplex scan. You say that the enrollee was admitted in November 2021 after 
an abnormal electrocardiogram identified ischemia and arterial disease. The Plan denied your request. The Plan 
says no prior authorization was obtained. 
 
 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. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the laboratory work provided on January 3, 2022, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the guided tissue regeneration (D4267), bone 
replacement graft (D7953), impression (D5100), and treatment stimulation using 3D image volume (D0393) 
provided from July 27, 2021, to August 27, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say you should be reimbursed for these 
services. The Plan denied your request. The Plan says that the services in this case are not covered. 
 
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 reimburse you for 
the guided tissue regeneration (D4267), bone replacement graft (D7953), impression (D5100), and treatment 
stimulation using 3D image volume (D0393) provided from July 27, 2021, to August 27, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
December 10, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you went to the 
emergency room for a nosebleed, and you talked to a doctor. You also say that he insisted on blood work, and 
you told him that you did not need blood work, because you are checked by your doctor twice a year. You also 
say they did blood work without permission, and you feel this bill is way too high. The Plan denied your 
request. The Plan says you were charged the correct cost sharing amount. 
 
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 $120 
copayment for Emergency Care.  
 You have been asked to pay a $120 copayment for emergency room services. emergency room services fall 
within the Emergency Care benefit category. The record shows that you were seen in the emergency room by a 
provider. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for emergency room services provided on 
December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the comprehensive oral evaluation 
(D0150) provided on December 2, 2021. 
 
You asked the Plan to pay the in network rate for the dental service. You say that the dental office advised they 
were in network. The Plan denied your request. The Plan says no additional payment will be made.  
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 and the service is listed as covered, 
there is a 50% coinsurance when you receive the oral evaluation out of network. Additionally, out of network 
dentists may bill you for any amount greater than what the plan pays. Therefore, we decided that the Plan does 
not have to pay the in network rate for the comprehensive oral evaluation (D0150) provided on December 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on January 3, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you had a scheduled appointment on 
December 12, 2021 and the facility rescheduled for January 3, 2022. You feel you should not have to pay the 
copayment since you had met your out-of-pocket max for 2021. The Plan denied your request. The Plan says 
you have been charged the correct copayment amount. 
 
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 Medicare-covered advanced diagnostic radiology services (such as CT scans, MRI, PET scans).  
 
 
 
  
You have been asked to pay a $150 copayment for the MRI. MRI 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. Therefore, we decided that the Plan does not have to waive the copayment for 
the MRI provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an osseous surgery (D4261) provided by an out-of-network 
provider on November 3, 2021. 
 
You asked the Plan to pay for an osseous surgery. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the correct cost sharing amounts have been applied to this claim. 
 
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 $100 
deductible and a 50% coinsurance for major dental services.  
 
You have been asked to pay a $100 deductible and a 50% coinsurance of the allowed amount for an osseous 
surgery. The total allowed amount after the $100 deductible is $41. The 50% coinsurance amount is $20.50 
($41 x 50% = $10.50). The total amount you are being asked to pay is $120.50 ($100 deductible + $20.50 
coinsurance = $120.50). An osseous surgery falls within the major dental 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 pay for an osseous surgery (D4261) provided by an out-of-network provider on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) and unspecified adjunctive procedure, by report (D9999) provided 
December 3, 2021. 
 
You asked the Plan to pay for the limited oral exam, tooth extraction and unspecified adjunctive procedure. 
You say that it was necessary to use this provider because you were in pain. The Plan denied your request. The 
Plan says these services are not covered because the provider has opted out of Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the limited 
oral exam, tooth extraction and unspecified adjunctive procedure when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. 
 
We looked at the file and Medicare rules. In this case the services were rendered by a provider who has opted 
out of Original Medicare. Based on this information, we decided that the Plan's rules for coverage of the 
limited oral exam, tooth extraction and unspecified adjunctive procedure have not been met. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) and unspecified adjunctive procedure, by report (D9999) provided 
December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on May 23, 2021. 
 
You asked the Plan to pay for the testing services. You say that the panel provides clinical decision support. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The claim shows the gene panel was billed with multiple codes. Only one 
code with one unit of service may be reported for a single procedure. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the gene panel provided on May 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on November 3, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on facility staff to verify 
eligibility and obtain authorization from the enrollee's insurance company. You say the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on November 3, 2021, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Targeted genomic sequence analysis provided on November 
15, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Targeted genomic sequence analysis. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
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 Targeted genomic sequence analysis provided on 
November 15, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D5067) provided by an out-
of-network provider on November 18, 2021. 
 
You asked the Plan to pay for a custom fabricated abutment. You say that an abutment was medically 
necessary. The Plan denied your request. The Plan says D6057 is not a covered dental 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 custom 
fabricated abutment (D5067) provided by an out-of-network provider on November 18, 2021.