Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services provided on September 15, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for therapy services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says the enrollee's primary care physician did not refer for services. The 
health plan requires utilization of network providers when possible and available and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.  
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 therapy services provided on September 15, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face down recovery chair (E1399), provided on March 7, 
2022, through April 4, 2022. 
 
You asked the Plan to pay for the face down recovery chair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the face down recovery chair (E1399), provided on March 7, 
2022, through April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on September 19, 2022. 
 
You asked the Plan to pay for the out-of-network dental services. You say that the services should be covered. 
The Plan denied your request. The Plan says their records do not show that your dentist is in their provider 
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 the dental services provided on September 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 1, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 a limited oral evaluation (D0140) provided on August 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on May 13, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered. 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. 
 
You have been asked to pay a $250 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery 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. You have been asked to pay $101.63 which is less than the standard $250 copayment for surgical 
services. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery 
provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dentures (D5110. D5120) provided on 
March 1, 2022. 
 
You asked the Plan to waive the coinsurance for the dentures. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the coinsurance applied correctly 
based on the services provided. 
 
  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 assess a 
40% coinsurance. 
 
The enrollee has been asked to pay a 40% coinsurance for the dentures (allowed amount is $1,551 x 40% = 
$620.56). This item/service falls within the comprehensive dental benefit category. This means that the enrollee 
has been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation they agreed to pay when the enrollee enrolled in the Plan. Therefore, we decided that the 
Plan does not have to waive the coinsurance for dentures (D5110. D5120) provided on March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code B4189 billed for date of service February 10, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee is receiving 42 grams of protein per 
bag. The Plan denied your request. The Plan says the code has an MUE value of 1. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code B4189 is parenteral nutrition solution; compounded 
amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any 
strength, 10 to 51 grams of protein  premix. 
 
We find that 7 units of CPT code B4189 was billed on one claim line. Code B4189 has an MUE value of 1 as a 
claim line edit. 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 procedure code B4189 billed 
for date of service February 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission services provided on June 9, 2022. 
 
You asked the Plan to pay for the inpatient admission services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the file shows that the enrollee was transferred to another hospital or distinct part of a hospital on June 9, 2022. The claim submitted reflects that the from and through 
dates are the same, however; it does not reflect condition code 40 which indicates a same day transfer. The Plan 
will review a corrected claim if submitted. Therefore, we decided that the Plan does not have to pay for the 
inpatient admission services provided on June 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided the enrollee does not meet the criteria for January 2, 2023 forward as this enrollee was not shown to be a danger to herself or others. There were no delusions, auditory or visual hallucinations noted. 
She was cooperative/compliant with treatment while not showing any threats the safety as she awaited nursing 
home placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of intra-socket biological dressing to aid in 
hemostasis or clot stabilization, per site (D7922) for teeth numbers 2 and 3 provided on August 17, 2022. 
 
You asked the Plan to pre-approve placement of intra-socket biological dressing to aid in hemostasis or clot 
stabilization, per site (D7922) for teeth numbers 2 and 3. You say that you were told you would not have to pay 
for the procedure. You also say you were given a documentation that said you had a $0 payment. The Plan 
denied your request. The Plan says this service is not covered under your contract under any circumstance. 
 
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 
placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922) for 
teeth numbers 2 and 3 provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
August 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the reason for this was you had an infection. 
You also say you are on disability and cannot pay. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 18, 2022. Therefore, 
we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on August 
12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve WoundFix skin substitute services. 
 
You asked the Plan to pre-approve WoundFix skin substitute services. You say that this is medically reasonable 
and necessary. The Plan denied your request. The Plan says medical literature does not show that the service is 
effective treatment for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of WoundFix skin substitute services 
have been met. Specifically, there are no medical records provided to determine the medical necessity of the 
requested procedure. Therefore, we decided that the Plan does not have to pre-approve WoundFix skin 
substitute services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet the diagnostic criteria of both 
Alzheimer's disease and frontotemporal dementia. There is no indication that the exam is being requested in the 
context of a clinical trial. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is only covered when there is a 
need to separate a differential diagnosis of frontotemporal dementia and Alzheimers disease. 
 
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 PET scan of the brain. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the records provided for review 
did not readily indicate that the enrollee's current condition meets diagnostic criteria for both AD and FTD. 
Therefore, the initial requirement of the NCD for coverage of this service would not have been met. Therefore, 
the request would not be medically 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 a PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says there was no prior authorization on file for the services provided. 
 
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 25, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the coronavirus test (87635) provided on May 31, 
2022. 
 
You asked the Plan to reimburse you for the coronavirus test. You say that you were charged 30 sterling for 
coronavirus antigen testing. You also say that you needed this test to fly back to the United States. The Plan 
denied your request. The Plan says the service you received outside of the United States was not urgent or 
emergent. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the coronavirus test have not been met. Specifically, the record shows that the service was for a "fit 
to fly" test, and thus not considered urgent or emergent. Therefore, we decided that the Plan does not have to 
reimburse you for the coronavirus test (87635) provided on May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Purewick external catheters and urine collection 
accessory kits, provided on December 23, 2020. 
 
You asked the Plan to pay for incontinence supplies. You say that these items should be covered. The Plan 
denied your request. The Plan says these items are not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for the Purewick external catheters and 
urine collection accessory kits, provided on December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental crown (D2740) provided on September 13, 2022. 
 
You asked the Plan to pay for the dental crown. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 a dental 
crown (D2740) provided on September 13, 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 March 
24, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be covered. 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 $5 
copayment for Specialist office visits. 
 
You have been asked to pay a $5 copayment for specialist office visit. This item/service falls within the 
Specialist 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 specialist 
office visit provided on March 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on March 07, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you cannot afford this 
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 $250 
copayment for Ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance transport. 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 transport 
provided on March 07, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehab stay provided on April 19, 
2022, to April 20, 2022. 
 
You asked the Plan to waive the copayment for inpatient rehab stay. You say that this should be covered. 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 $395 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $395 copayment for inpatient rehab 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 inpatient 
rehab stay provided on April 19, 2022, to April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) 
provided on September 27, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation-problem focused (D0140) provided on September 27, 2022.