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

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan provided 
on January 26, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT) scan. 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 $225 
copayment for outpatient diagnostic tests/computed tomography (CT). 
 
You have been asked to pay a $225 copayment for computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests/computed tomography (CT) 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 computed tomography (CT) scan provided on January 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
in-network provider from July 15, 2022, to July 22, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not agree with 
paying the copayment for this service. 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 in-network hospital admission. 
 
You have been asked to pay a $250 copayment for the inpatient hospital stay. 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 by an in-network provider from July 15, 2022, to July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the single vision sphere, the polycarbonate lens, the 
miscellaneous vision item, the variable sphericity lens, the polarization, the antireflective coating, the scratch-
resistant coating, the lens tinting, and the ultraviolet lens provided on December 12, 2022. 
 
You asked the Plan to pay for the vision services. You say that you should not be responsible for the remaining 
$40.01 because the Plan only paid $280 towards the services. You say that is less than the $400 allowance. The 
Plan denied your request. The Plan says the claim processed correctly. 
 
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 with a $400 benefit towards the purchase and fitting of eyeglasses. 
 
We looked at the file and the Plan's rules. Specifically, the Plan deducted $400 of the retail price of the 
services. Based on this information, we decided that the Plan's rules for coverage of the vision services have 
not been met. Therefore, we decided that the Plan does not have to pay for the single vision sphere, the 
polycarbonate lens, the miscellaneous vision item, the variable sphericity lens, the polarization, the 
antireflective coating, the scratch-resistant coating, the lens tinting, and the ultraviolet lens provided on 
December 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation trips (A0120). 
 
You asked the Plan to pre-approve routine transportation trips. You say that you need transportation to your 
medical appointments. The Plan denied your request. The Plan says routine transportation is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation trips have not been met. Therefore, we decided 
that the Plan does not have to pre-approve routine transportation trips (A0120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ReActiv8 Implantable Neurostimulation System. 
 
You asked the Plan to pre-approve the ReActiv8 Implantable Neurostimulation System. You say that the 
service is medically necessary. The Plan denied your request. The Plan says this service is considered 
experimental. 
 
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 ReActiv8 Implantable 
Neurostimulation System. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational 
procedure and device. 
 
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 ReActiv8 Implantable Neurostimulation System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the ReActiv8 Implantable Neurostimulation 
System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle group 1 standard (motorized 
scooter) (K0800). 
 
You asked the Plan to pre-approve a motorized scooter. You say that the enrollee is a fall risk and is unable to 
ambulate. The Plan denied your request. The Plan says the enrollee does not meet requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
   
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 motorized scooter. Our reviewer says 
that criteria for coverage has not been met. Our physician reviewer found the enrollee has a personal mobility 
deficit, but the documentation is not specific as to whether this deficit impairs participation in mobility related 
activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations 
within the home. The documentation is not clear that the enrollee is unable to ameliorate this deficit but a 
manual wheelchair. The documentation does not reveal a home evaluation indicating that this enrollee can 
safely use the power operated vehicle Group 1 standard in the home. 
 
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 motorized scooter have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power operated vehicle group 1 standard (motorized scooter) (K0800).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 24, 2022, 
to October 5, 2022. 
 
You asked the Plan to pay for the billed services. You say that the final claim complies with billing guidelines. 
The Plan denied your request. The Plan says the claim was billed with an invalid or missing value code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim submitted does not include a value code or amount as required. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
September 24, 2022, to October 5, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided by an 
in-network provider on December 2, 2022, and the eye imaging performed by an in-network provider on 
December 5, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit and the eye imaging. You say that 
you would like the cost sharing for these services to be lower. 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 $50 
copayment for in-network emergency room services, and a $12 copayment for in-network basic radiological 
services performed at an outpatient hospital. 
 You have been asked to pay a $50 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. You have also been asked to pay a $12 copayment for the eye imaging. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the emergency room visit provided by an in-network 
provider on December 2, 2022, and the eye imaging performed by an in-network provider on December 5, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
November 22, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you do not think you 
should owe anything for this service. 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 $20 
copayment for each in-network basic imaging service. 
 
You have been asked to pay a $20 copayment for a diagnostic mammogram. This item/service falls within the 
each in-network basic imaging 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. Therefore, we decided that the Plan does not have to waive the copayment for a 
diagnostic mammogram provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on January 
22, 2020, to July 25, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. 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 $50 
copayment and $45 copayment per visit for physician/practitioner services/specialist visit.  
 
You have been asked to pay a $50 copayment and $45 copayment per visit for specialist office visit. The total 
amount you are being asked to pay is $325 ($50 + $50 + $45 +$45 +$45 +$45 +$45 =$325). This item/service 
falls within the physician/practitioner services/specialist visit 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 specialist office visit provided on January 22, 2020, to July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on October 18, 2022. 
 
You asked the Plan to pay for dental services. You say that you think x-rays should be billed separately. The 
Plan denied your request. The Plan says this service is 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 Plans coverage rules apply in this case. Intraoral - complete series of 
radiographic images (D0210) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0210 is not among 
those covered under this benefit. However, the Plan did agree to pay for the bitewing x-ray portion of the 
service. Therefore, we decided that the Plan does not have to pay for intraoral - complete series of radiographic 
images (D0210) provided on October 18, 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 
July 4, 2022, to July 9, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford this 
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 $275 
copayment per day, for days 1 to 7 for inpatient hospital care. 
 
You have been asked to pay a $275 copayment per day, for days 1 to 5 of the inpatient hospital stay ($275 
copayment x 5 days = $1,375). 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 July 4, 2022, to 
July 9, 2022.
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 need the device so you can 
check your glucose often and it will help you to be aware of the high levels. The Plan denied your request. The 
Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750) and progressive lens 
(V2781) provided on August 31, 2022. 
 
You asked the Plan to pay for the anti-reflective coating and progressive lens. You say that the treating 
provider is in-network, and these lenses should be covered. The Plan denied your request. The Plan says while 
the provider is in-network, additional upgrade options are explicitly listed as not covered under the Vision Care 
benefit in the Evidence of Coverage. 
 
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 single vision, lined bifocal, lined trifocal, lenticular, and Tier I (standard) progressive 
lenses. 
 
 
 We looked at the file and the Plan's rules. Specifically, the lenses you received are considered upgrades that are 
excluded from coverage. Based on this information, we decided that the Plan's rules for coverage of the anti-
reflective coating and progressive lens have not been met. Therefore, we decided that the Plan does not have to 
pay for the anti-reflective coating (V2750) and progressive lens (V2781) provided on August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment 
supported crown (D6058) provided on November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental work was necessary and not done for 
cosmetic reasons. The Plan denied your request. The Plan says these services are not covered by the Plan's 
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 the 
custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from October 25, 2022, to 
October 29, 2022, by the out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the services were approved. The Plan denied 
your request. The Plan says there is insufficient documentation to support why the services should be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 medical services have been met. 
Specifically, there is no documentation to support how the enrollee came to the servicing provider, whether the 
services were performed as billed, or whether the services were medically necessary. The record indicates that 
the Plan made multiple attempts to obtain this information but none was received. Therefore, we decided that 
the Plan does not have to pay for the medical services provided from October 25, 2022, to October 29, 2022, by 
the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic hearing exam provided on 
November 10, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic hearing exam. You say that this should have 
been included with the office visit charge. 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 $45 
copayment for diagnostic hearing exams. 
 
You have been asked to pay a $45 copayment for the diagnostic hearing exam. This item/service falls within 
the diagnostic hearing exams 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. However, since the allowed amount is less than the standard copayment, you only owe 
$39.60. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic hearing 
exam provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), deep sedation/general 
anesthesia  first 15 minutes (D9222) and deep sedation/general anesthesia  each subsequent 15-minute 
increment (D9223) provided on October 12, 2022. 
 
You asked the Plan to pay for dental services. You say that you had a fractured tooth that caused extreme pain, 
which resulted in needing an extraction. You feel your insurance should cover the billed services. The Plan 
denied your request. The Plan says this service is not covered under your Plan. 
 
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 extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated 
(D7210), deep sedation/general anesthesia  first 15 minutes (D9222) and deep sedation/general anesthesia  
each subsequent 15-minute increment (D9223) provided on October 12, 2022.