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

 
We decided that the Plan does not have to waive the copayment for an office visit (99213) provided on 
December 3, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 You have been asked to pay a $10 copayment for an office visit. 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 office visit (99213) provided on December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 10, 
2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 You have been asked to pay a $45 copayment for the specialist office visit. 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 specialist visit provided on December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory work provided by a participating 
provider on December 9, 2021. 
 
You asked the Plan to waive the copayment for the laboratory work. You say that you had the laboratory work 
done at her primary care physician's office. The Plan denied your request. The Plan says you have been asked 
to pay 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 $45 
copayment for laboratory services at an in-network outpatient hospital. For this date of service, you have been 
asked to pay the allowed amount of the claim because this amount is less than the standard $45 copayment for 
the laboratory work. 
 
You have been asked to pay a $25.79 copayment for the laboratory work. The laboratory work falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. The record shows you 
were billed by the hospital facility. 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 laboratory work 
provided by a participating provider on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular implant/abutment supported fixed denture 
for edentulous arch (D6115). 
 
You asked the Plan to pre-approve a mandibular implant/abutment supported fixed denture. You say that this 
denture is medically necessary. The Plan denied your request. The Plan says this service is not a covered 
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 pre-approve a 
mandibular implant/abutment supported fixed denture for edentulous arch (D6115).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 28, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was incorrectly coded. 
 
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 find that CPT code  is not supported in the medical record. We find that the various denied CPT codes are 
not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 
81479. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee 
on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diabetic supplies provided on September 
22, 2021. 
 
You asked the Plan to waive the copayment for diabetic supplies. You say that these were sent in September, 
but not processed until December. You also say that you have never paid anything for these pump supplies, and 
on December 25, 2021, a different claim of the same identical order was fully covered. 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 20% 
coinsurance for Medicare-covered benefits for durable medical equipment (DME) and related supplies.  
 
 
 
 
 You have been asked to pay $63 in coinsurance, which is 20% of the allowed amount for diabetic supplies 
($315 allowed amount x 20% coinsurance = $63). Diabetic supplies fall within the durable medical equipment 
(DME) and related 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 diabetic 
supplies provided on September 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (76641) provided on 
December 10, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $55 copayment for an ultrasound. Ultrasounds fall 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 an ultrasound (76641) provided on December 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the physical therapy. You say that due to the enrollee's condition, lack of 
transportation, circumstances with the coronavirus, your office location and appointment availability is more 
convenient for the enrollee. The Plan denied your request. The Plan says the provider is out-of-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. The records provided for review do not show that the service at 
issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve physical therapy 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 pre-approve the cardiologist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the cardiologist office visit. You say that your current cardiologist is not 
responsive and is unreliable. The Plan denied your request. The Plan says the provider is out-of-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 
the cardiologist office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for coverage have not been 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 a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require 
aggressive therapies by an intensive team. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our physician reviewer found 
that you were admitted to the acute care hospital for kyphoplasty and sacroplasty services after a fall. Your 
medical problems are stable. You do not require treatment by multiple therapies in an intensive rehabilitation 
therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of 
a need for an intensive rehabilitation program. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full mouth debridement to enable a comprehensive 
oral evaluation and diagnosis on a subsequent visit (D4355). 
 
You asked the Plan to pre-approve the full mouth debridement. You say that you feel that this service should be 
covered. The Plan denied your request. The Plan says the comprehensive oral evaluation (D0150) should be 
completed on a subsequent visit, not on the same day, to allow the gingiva to heal and allow for a thorough 
comprehensive oral exam. The Plan also says that you received a regular cleaning, or oral or periodontal 
evaluation within the last 12 months, and you cannot get this type of deep cleaning of your whole mouth within 
12 months of these types of visits. 
 
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, a full mouth debridement at appeal is 
to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355). This service is not 
allowed within 12 months of receiving a comprehensive oral evaluation (D0150). The record shows that you 
received a comprehensive oral evaluation (D0150) on December 22, 2021, and you cannot receive the full 
mouth debridement (D4355) within 12 months of this visit. Therefore, we decided that the Plan does not have 
to pre-approve a full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a 
subsequent visit (D4355).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the acute facility knows that the patient 
needs physical therapy for more than 2 weeks. The patient is on a ventilator and needs weaning. The Plan 
denied your request. The Plan says the patient is still too acute and no documentation of failed vent weaning 
has been provided. The patient's needs are being met in the current acute setting and LTACH would add no 
additional services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found The patient appears to be somewhat unstable still and requires additional short-term 
acute care to further stabilize that can be safely completed at the current facility for now. The patient does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that the patient requires that are not already available and covered at the current facility. Transfer to 
LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed and the patient is more stable for transfer.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are par 
providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) services 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 the FreeStyle Libre Continuous Glucose Monitor 
(CGM). 
 
You asked the Plan to pre-approve the FreeStyle Libre CGM. You say that you would like reconsideration 
because testing your blood glucose levels is painful. The Plan denied your request. The Plan says you do not 
meet Medicare criteria for coverage. 
 
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 FreeStyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle 
Libre Continuous Glucose Monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on October 27, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that when you went to the 
first visit you were only given an antibiotic for the abscessed tooth, which was very painful, and it was not 
strong enough to clear up the infection. You also say that when you went to the second visit you were told your 
tooth was cracked and would have to be pulled. The Plan denied your request. The Plan says this service 
exceeds the frequency limitation in your benefit 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. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on September 15, 2021 and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation (D0140) provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two surgical placements of implant bodies: endosteal 
implants (D6010 x2), two bone replacement grafts for ridge preservation (D7953 x2), and five adjunctive 
procedures (D9999 x5) provided from May 20, 2021, to October 13, 2021. 
 
You asked the Plan to pay for the endosteal implants, bone replacement grafts, and adjunctive procedures. You 
say that the provider did not tell you they did not accept your insurance. The Plan denied your request. The 
Plan says these services are not covered benefits under your dental 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. 
 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 two 
surgical placements of implant bodies: endosteal implants (D6010 x2), two bone replacement grafts for ridge 
preservation (D7953 x2), and five adjunctive procedures (D9999 x5) provided from May 20, 2021, to October 
13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 28, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that while you make your best efforts to adhere to 
the authorization policy, there are occasional situations that prevent you from meeting the guidelines as 
required. The Plan denied your request. The Plan says the rendering provider is a non-participating provider 
and there is no referring provider involved in these services. The Plan also says that they did not authorize any 
services for the rendering provider nor for the facility. 
 
 
 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 laboratory services provided on May 28, 2021, by 
an out-of-network (OON) provider.