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

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 
20, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were informed you 
would not have to pay 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 for specialist visits. 
 
You have been asked to pay a $50 copayment for the specialist office visit. This item/service falls within the 
specialist visits 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 specialist office visit 
provided on May 20, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail zoledronic acid first. 
 
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 Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drug. Based on the medical records 
provided and the Medicare-approved major drug compendia there is no indication that the Plan's required drug 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on May 14, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each Specialist office visit for Medicare-covered services. Covered services include 
consultation, diagnosis, and treatment by a specialist. 
 
You have been asked to pay a $40 copayment for office visit. This item/service falls within the 
Physician/practitioner services, including doctor's office visits 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 office visit on May 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on May 
06, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you had terrible 
treatment at this ER and want your copayment removed. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
emergency 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 an emergency room visit 
provided on May 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received 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 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 May 26, 2022, 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 and a visual field examination provided on 
May 24, 2022, by an OON provider. 
 
You asked the Plan to pay for an office visit and a visual field examination. You say that this provider is the 
only full service low vision care in the area. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
 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 and a visual field examination 
provided on May 24, 2022, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 07, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not be responsible 
to pay this. 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 $440 
copayment for ambulance services. 
 
You have been asked to pay a $440 copayment for ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on May 07, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgery provided on February 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a surgery. You say that you were informed by a representative from the Plan that 
no precertification was required for CPT code 20680. The Plan denied your request. The Plan says the decision 
to deny the claim is correct because an authorization was not obtained prior to services being performed. 
 
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 surgery provided on February 22, 2022, 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 flexible protective outer surface covering system 
(L5962). 
 
You asked the Plan to pre-approve a flexible protective outer surface covering system. You say that this 
prosthetic accessory is necessary for you. The Plan denied your request. The Plan says there is no indication 
that you are exposed to harsh condition or engage in extraordinary activities that require extra protection from a 
specialized prosthetic cover. 
 
The Plan must follow Medicare rules. Medicare rules say that protective outer surface covering systems 
(L5962, L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are 
used by a beneficiary who has special needs for protection against unusually harsh environmental situations 
where it is necessary to protect the lower limb prosthesis beyond the normal level of protection.   
 
We looked at the file and Medicare rules. In this case, there is no indication that you have special needs for 
protection against unusually harsh environmental situations. Based on this information, we decided that 
Medicare rules for coverage of a flexible protective outer surface covering system have not been met. Therefore, we decided that the Plan does not have to pre-approve a flexible protective outer surface covering 
system (L5962).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a cataract injection procedure provided on 
May 18, 2022. 
 
You asked the Plan to waive the cost share for a cataract injection procedure. You say that you already paid a 
copayment for the procedure, you should not have to pay for the injection as well. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and a 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this item or service was $842.13, 
resulting in a coinsurance of $168.43 ($842.13 x 20% = $168.43). 
 
 
 You have been asked to pay a $250 copayment for outpatient surgery, including services provided at hospital 
outpatient facilities and a $168.43 coinsurance for Medicare Part B prescription drugs benefit category ($250 + 
$168.43 = $418.43). 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 a cataract injection procedure provided on May 
18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210 and D0220) and an extraction 
(D7210) provided by an out-of-network provider on May 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were in a lot of pain, and you went to the 
closest dentist. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for intraoral imaging (D0210 and D0220) and an extraction (D7210) provided by an out-of-network 
provider on May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoe lift you received on May 13, 2020. 
 
You asked the Plan to pay for the shoe lift. You say that this should not be denied for untimely filing because 
you attempted to get prior authorization from the Plan. The Plan denied your request. The Plan says you did not 
timely file this claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the shoe lift was not filed until May 3, 2022. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the shoe lift you received on May 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro 2 Motion with elbow orthosis (L8701).

You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by their family practice physician for myoelectric orthotic restoration, using the MyoPro Motion W. The Plan denied your request. The Plan says this device is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.  

We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro 2 Motion with elbow orthosis (L8701).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bed side rails, full length (E0310) and a gel pressure 
mattress pad (E0185). 
 
You asked the Plan to pre-approve bed side rails and a mattress. You say that you disagree with the decision 
and have attached clinicals to support why the enrollee needs the medical equipment. The Plan denied your 
request. The Plan says documentation submitted does not support medical necessity for the requested items. 
 
The Plan must follow Medicare rules. The rules say that side rails are covered when they are required by the 
beneficiary's condition and they are an integral part of, or an accessory to, a covered hospital bed. The rules 
also say a group 1 mattress overlay or mattress is covered if one of the three criterias are met. 
 
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 bed side rails and a mattress. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee is not 
immobile or at high risk for skin breakdown. The rationale for full side rails is not apparent. Full side rails are a 
well-documented injury hazard and are generally not employed. There is no evidence the requested side rails 
are reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bed side rails and a mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bed side rails, full length (E0310) and a gel pressure mattress pad (E0185).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921), other drugs/medicaments 
(D9630), and diagnostic casts (D0470) provided on November 9, 2021, an unspecified removable prosthodontic procedure (D5899) provided on November 17, 2021, and core build up (D2950) provided on 
December 6, 2021.  
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says gingival irrigation (D4921), other drugs/medicaments (D9630), 
diagnostic casts (D0470), an unspecified removable prosthodontic procedure (D5899), and core build up 
(D2950) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 gingival 
irrigation (D4921), other drugs/medicaments (D9630), and diagnostic casts (D0470) provided on November 9, 
2021, an unspecified removable prosthodontic procedure (D5899) provided on November 17, 2021, and core 
build up (D2950) provided on December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard  hard appliance, full arch (D9944) 
provided on March 31, 2022. 
 
You asked the Plan to pay for an occlusal guard  hard appliance, full arch (D9944). You say that the mouth 
guard is necessary because the small ones that only cover the front teeth changes the bite. You say that this 
saves the cost of a cap and ultimately a root canal. The Plan denied your request. The Plan says this service is 
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 an 
occlusal guard  hard appliance, full arch (D9944) provided on March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the sales tax (S9999) provided from September 8, 
2021, to September 9, 2021. 
 
You asked the Plan to reimburse you for the sales tax. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says they have reimbursed you for the semi-electric 
hospital bed less your cost share amount. The Plan says the sales tax is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say contractors do not make any additional payment for sales 
taxes. 
 
We looked at the file and Medicare rules. In this case, the Plan has approved reimbursement, less your cost 
share, for the semi-electric hospital bed. However, Medicare does not make separate payment for sales tax. 
Therefore, we decided that the Plan does not have to reimburse you for the sales tax (S9999) provided from 
September 8, 2021, to September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic on July 20, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for diagnostic procedures and tests at outpatient hospital. Covered services include but are not 
limited to other outpatient diagnostic tests. 
 
You have been asked to pay a $200 copayment for outpatient diagnostic. 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 outpatient diagnostic on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274), a periodic oral evaluation (D0120), and 
prophylaxis (D1110), provided by an out-of-network provider on March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the plan should pay for this. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for bitewings (D0274), a periodic oral evaluation (D0120), and prophylaxis (D1110), provided by an 
out-of-network provider on March 22, 2022.