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

 
We decided that the Plan does not have to pay for the reline of a complete maxillary denture (D5750) provided 
on October 25, 2021. 
 
You asked the Plan to pay for the denture reline. You say that you would like to appeal this service. The Plan 
denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also 
says that you have no supplemental dental rider benefits which would allow you to have additional dental 
benefits. 
 
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 pay for the reline 
of a complete maxillary denture (D5750) provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit (99213) provided on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for the telehealth 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 $40 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $40 copayment for a telehealth visit. Telehealth visits fall within the 
Physician/Practitioner services, including doctors 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 a telehealth visit (99213) provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit and hematoma drainage 
(99202, 10140) provided on December 1, 2021. 
 
You asked the Plan to waive the deductible for the office visit and hematoma drainage. 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. Your 
contract with the Plan says that there is a $150 deductible which applies to Physician/Practitioner services, 
including doctor's office visits and Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner services, including doctor's office visits and Outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $150 deductible which applies to Physician/Practitioner 
services, including doctor's office visits and Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not 
been met at the time the office visit and hematoma drainage was received on December 1, 2021. Therefore, we 
decided that the Plan does not have to waive the deductible for an office visit and hematoma drainage (99202, 
10140) provided on December 1, 2021.  
 
Since the $150 deductible was met, you have also been asked to pay a $35 copayment for the office visit and a 
5% coinsurance for the hematoma drainage ($3.63). 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and removal of an 
impacted tooth, partially bony (D7230) provided on June 15, 2021. 
 
You asked the Plan to pay for the limited oral evaluation and removal of impacted tooth. You say that you 
confirmed that your copayment was only $50. You say that you were double charged for the services. You also 
say that every time you visited the dentist, you asked if the entire service would be covered, and you were 
never told. The Plan denied your request. The Plan says the services 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 limited oral evaluation and removal 
of impacted tooth are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation (D0140), and removal of an impacted tooth, partially bony (D7230) 
provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening (D0190) and simple extraction (D7140) 
provided on August 5, 2021, and August 30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the screening and simple extraction. You say that you had no choice but to seek 
assistance from a trusted alternative for these services because the Plan's in-network providers declined to help 
you with your toothache. The Plan denied your request. The Plan says the screening is not a covered expense 
under your dental plan. The Plan says that services performed by an OON provider are not covered because 
your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to 
the date of service to verify benefits and provider eligibility.  
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 screening (D0190) is not among 
those covered under this benefit. You are also responsible for 100% of the cost for dental services rendered by 
an OON provider. Therefore, we decided that the Plan does not have to pay for the screening (D0190) and 
simple extraction (D7140) provided on August 5, 2021, and August 30, 2021 by an out-of-network (OON) provider.
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 LTACH care is medically reasonable and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in the current acute care facility. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care facility. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation treatment devices, a penicillin g benzathine 
injection, and a therapeutic, prophylactic, or diagnostic injection provided on November 17, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for radiation treatment devices, a penicillin g benzathine injection, and a therapeutic, 
prophylactic, or diagnostic injection. You say that you are in disagreement with this determination and request 
that the claim be reviewed and reprocessed based on the medical necessity of the services provided. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan, and they have also 
determined that these services are not urgent or emergent, nor were they approved in advance.  
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 radiation treatment devices, a penicillin g 
benzathine injection, and a therapeutic, prophylactic, or diagnostic injection provided on November 17, 2021, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2740) for tooth #'s 24 and 25. 
 
You asked the Plan to pre-approve the crowns. You say that tooth #'s 24 and 25 have severe breakdown due to 
trauma from bruxism. You also say that the dentin is exposed and may need root canals if not treated with 
crown coverage due to the severe tooth breakdown. The Plan denied your request. The Plan says that there is 
no clinical evidence to support medical necessity. 
 
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 crowns 
when the services are medically necessary and reasonable.  
 
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 crowns. Our reviewer says that the 
documentation meets the criteria for coverage for crown restorations (D2740) for tooth #'s 24 and 25. Our 
physician reviewer found tooth #'s 24 and 25 exhibit significant coronal breakdown incisally along with 
vertical fracture lines. Our reviewer also found that crown restorations are reasonable and necessary to provide 
support and adequate function and to prevent further breakdown which would lead to the loss of these teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan has to pre-
approve crowns (D2740) for tooth #'s 24 and 25.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty-six (26) physical therapy visits (CPT code 
97110). 
 
You asked the Plan to pre-approve the physical therapy visits. You say that the visits are necessary. The Plan 
denied your request. The Plan says since you are making steady progress and you have the potential to further 
improve, the Plan can approve 10 additional physical therapy visits. The Plan states this should allow you to 
continue your progress and receive further instructions through a home exercise program. The Plan states the 
additional 26 visits are not approved as they are not considered medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the additional requested therapy generally is not 
accepted as specific and effective therapy for your condition beyond what was approved by the health plan. 
You have had prior therapy and the documentation does not reveal that you require the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist beyond what was approved. The 
requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. There has been instruction in an independent home 
program. Ongoing skilled therapy is not medically necessary for your remaining deficits beyond what was 
already approved. 
 
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 physical therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve twenty-six (26) physical therapy visits (CPT code 97110).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
December 2, 2021. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that your husband asked if 
the enrollee could be transported to another facility, he was told it would have to be by ambulance. The Plan 
denied your request. The Plan says copayment is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $200 copayment per one-way trip (includes ground and air transport) for each Medicare-covered, 
ambulance service.  
  The enrollee has been asked to pay $200 copayment for ambulance transportation. Ambulance transportation 
falls within the Ambulance services benefit category. Ambulance transportation must be arranged through 
the Plans transportation vendor to be covered at no cost to the enrollee. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the ambulance transportation provided on December 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasonic guidance received on November 
5, 2021. 
 
You asked the Plan to waive the copayment for ultrasonic guidance. You say that you don't understand why the 
Plan refused to pay for this service. The Plan denied your request. The Plan says the copayment was applied 
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 $110 
copayment for in-network Medicare-covered radiological diagnostic services, not including X- rays, performed 
in a physicians office or at a free-standing facility (such as a radiology center or medical clinic) for the 
ultrasonic guidance. 
 
You have only been asked to pay a total of $56.36. Since the allowed amount was only $56.36 the Plan charged 
you $56.36 instead of the standard $110 copayment. Ultrasonic guidance falls within the Other outpatient 
diagnostic tests - Radiological diagnostic services, not including x-rays 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 ultrasonic guidance received on November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
November 1, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that no copayment is due because 
this was part of an annual wellness visit. The Plan denied your request. The Plan says copayment is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $35 copayment for laboratory services in an outpatient hospital.  
 
The enrollee has been asked to pay $35 copayment for laboratory services. Laboratory services fall within the 
Outpatient hospital services benefit category. Laboratory services are not covered under the annual wellness 
benefit. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services provided 
on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 14, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that the provider should have submitted 
the claim to the VA.  The Plan denied your request. The Plan says you have been charged the correct 
copayment amount. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay $40 for copayment per specialist visit. 
 
You have been asked to pay $40 copayment for the office visit. An office visit falls within the 
Physician/Practitioner services, including doctors 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 an office visit provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the heart provided on 
December 21, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says you have been 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $235 copayment for diagnostic radiology services, including ultrasounds at an outpatient hospital.  
 
 The enrollee has been asked to pay a $235 copayment for an ultrasound. An ultrasound falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an ultrasound of the heart provided on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an anesthesia consultation visit provided on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for an anesthesia consultation visit. You say that you had 
outpatient surgery and paid the surgery copayment. You also say you are now getting a bill for $40 copayment. 
The Plan denied your request. The Plan says you have been 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 $40 
copayment for a specialist visit, including outpatient clinic visits. The contract also says that unless the 
provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient hospital services. 
 
The record shows you had an anesthesia consultation visit on November 8, 2021, which has a cost sharing 
amount. You have been asked to pay a $40 copayment for an anesthesia consultation visit. An anesthesia 
consultation visit falls within the Outpatient Hospital 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 an anesthesia consultation visit provided on November 8, 2021.