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

 
We decided that the Plan does not have to waive the cost share for outpatient diagnostic procedures, outpatient 
surgical procedure, and specialist visit provided on September 8, 2022, to September 21, 2022. 
 You asked the Plan to waive the cost share for outpatient diagnostic procedures, outpatient surgical procedure, 
and specialist visit. You say that you are disputing the share cost. 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies, $310 copayment for outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers, and $40 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay 20% coinsurance for outpatient diagnostic procedures, $310 copayment for 
outpatient surgical procedure, and $40 for a specialist visit. These items/services fall within the outpatient 
diagnostic tests and therapeutic services and supplies, outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers, and physician/practitioner services, including 
doctor's office visits benefit categories. 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 outpatient 
diagnostic procedures, outpatient surgical procedure, and specialist visit provided on September 8, 2022, to 
September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), progressive lenses (V2781), anti-reflective 
coating (V2750) and a vision item (V2799) provided on September 12, 2022.  
You asked the Plan to pay for frames (V2020), progressive lenses (V2781), anti-reflective coating (V2750) and 
a vision item (V2799). You say that this provider is in-network. The Plan denied your request. The Plan says 
per your benefits, you are responsible for all eyewear costs not purchased from a Plan vision network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you receive services from a Plan vision provider. 
 
We looked at the file and the Plan's rules. when the eyewear is purchased from a Plan vision provider. The 
record shows the provider you went to is no in-network with the Plan. Based on this information, we decided 
that the Plan's rules for coverage of frames (V2020), progressive lenses (V2781), anti-reflective coating 
(V2750) and a vision item (V2799) have not been met. Therefore, we decided that the Plan does not have to 
pay for frames (V2020), progressive lenses (V2781), anti-reflective coating (V2750) and a vision item (V2799) 
provided on September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on September 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 September 1, 2022. 
Therefore, we decided that the Plan does not have to pay for dental services provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate denture - maxillary (D5130) provided on October 
3, 2022. 
 
You asked the Plan to pay for dental services. You say that your provider said dentures would improve your 
health, your teeth are bad, and you have daily headaches. The Plan denied your request. The Plan says this 
service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Immediate denture - maxillary 
(D5130) is not covered under the Plans dental benefits. 
 
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 
immediate denture - maxillary (D5130) provided on October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), intravenous 
moderate (conscious) sedation/analgesia- first 15 minutes (D9239), and sedation/analgesia each subsequent 15 
minute (D9243 x2) provided on October 5, 2022. 
 
 
 You asked the Plan to pay for the dental services. You say that the extraction was not done for cosmetic 
reasons. You also say that you had a pocket and the only way to clear that was to extract the tooth and then 
rebuild the bone. The Plan denied your request. The Plan says these services are not covered under the benefit 
package or are covered but subject to a 20% coinsurance. 
 
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 bone 
replacement graft for ridge preservation - per site (D7953), extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210), intravenous moderate (conscious) sedation/analgesia- first 15 minutes 
(D9239), and sedation/analgesia each subsequent 15 minute (D9243 x2) provided on October 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transport service provided on December 
16, 2021. 
 You asked the Plan to pay for the air ambulance transport service. You say that it was reasonable and medically 
necessary for the air ambulance utilization for time sensitive cardiac conditions. The Plan denied your request. 
The Plan says the service does not meet reasonable and necessary requirements. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 pay for the air ambulance transport service. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the provided medical 
records document that the enrollee suffered from an illness or injury that contraindicated transportation by any 
means other than ambulance. The enrollee was experiencing chest pain with a significant cardiac history. The 
records do not document that ground transportation to an appropriate medical center would have been 
prohibitively lengthy. A hospital with capabilities to evaluate a cardiac patient was 18-20 miles away by 
ground transportation. 
 
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 air ambulance transport service have not been met. Therefore, we decided 
that the Plan does not have to pay for the air ambulance transport service provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve custom fabricated abutmentsincludes placement (D6057 x 3) and 
abutment supported porcelain/ceramic crowns (D6058 x 3). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that these items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, our organization requested a list of covered dental codes from the 
Plan as the Evidence of Coverage booklet does not clearly state covered dental services. However, the Plan has 
not provided this information. The Plan has not substantiated their denial; therefore, we must find in your 
favor. Therefore, we decided that the Plan has to pre-approve custom fabricated abutmentsincludes placement 
(D6057 x 3) and abutment supported porcelain/ceramic crowns (D6058 x 3).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for walker provided on March 30, 2022. 
 
You asked the Plan to waive the deductible for walker. 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 $150 
deductible for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay a $150 deductible for walker. This item/service falls 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 deductible 
for walker provided on March 30, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mental health visit provided on July 25, 
2022, to August 25, 2022. 
 
You asked the Plan to waive the copayment for mental health 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 $15 
copayment for Outpatient mental health. 
 
You have been asked to pay a $15 copayment for mental health visit. This item/service falls within the 
Outpatient mental health 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 $30 ($15 x 2 visits) copayment for the mental health visits. 
Therefore, we decided that the Plan does not have to waive the copayment for mental health visit provided on 
July 25, 2022, to August 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on May 16, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. 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 $115 
copayment for Radiological diagnostic services. 
 
You have been asked to pay a $115 copayment for ultrasound. This item/service falls within the Radiological 
diagnostic 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. You have been asked to pay $114.55 which is less than the standard $115 copayment for an 
ultrasound. Therefore, we decided that the Plan does not have to waive the copayment for ultrasound provided 
on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that a 
ventilator Our physician reviewer found a home ventilator is not medically necessary. This enrollee has chronic 
obstructive pulmonary disease (COPD), heart failure with preserved ejection fraction (HFpEF), and 
paroxysmal atrial fibrillation (AF). Arterial blood gas (ABG) during a recent hospitalization was consistent 
with acute on chronic carbon dioxide (CO2) retention. This enrollee may benefit from bilevel positive airway 
pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an outpatient. There is no documentation that this was tried and failed. Medicare does not cover a home ventilator when used as 
BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional outpatient physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. 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 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 12 additional outpatient 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 based on the medical records 
provided there is contradictory information with regard to the enrollee's needs and functional abilities. Medical 
notes were providing arguing for the need for continued therapy, yet these same notes document no difficulties 
with walking, dressing, bathing, climbing stairs and taking care of herself. After 23 physical therapy 
treatments, records do not support that the complexity of the enrollee's conditions are such that the skills of a 
professional therapist are required to achieve further improvement or to maintain the enrollee's symptoms or 
functional status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 additional outpatient physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 12 additional outpatient physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Triamcinolone acetonide injection provided on September 
19, 2022. 
 
You asked the Plan to pay for Triamcinolone acetonide injection. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for Triamcinolone acetonide 
injection provided on September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 21, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on September 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist visit provided on July 06, 2022. 
 
You asked the Plan to pay for specialist visit. You say that that you were referred to the out-of-network 
specialist, so you proceeded with the appointment. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for specialist visit provided 
on July 06, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on May 25, 2022, to June 18, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that you were told 
there would be no charge for 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 $150 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $150 copayment for skilled nursing facility (SNF) care. This item/service falls 
within the Skilled nursing facility (SNF) 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. You have been asked to pay a $600 ($150 x 4 days) copayment for your 
SNF care. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility 
(SNF) care provided on May 25, 2022, to June 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5298) provided on August 2, 2022. 
 
You asked the Plan to pay for hearing aids (V5298). You say that had you known potential hearing aid 
coverage was pending, you could have taken her to the in-network provider. The Plan denied your request. The 
Plan says there is no coverage of hearing aids or related services that if they are received from an out-of-
network provider. The Plan also says that the hearing benefit is not covered if the services are not registered 
with the Plan hearing in advance. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased by an in-network Plan hearing provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5298) have not been met. Therefore, we decided that the Plan does not have to pay 
for hearing aids (V5298) provided on August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
October 4, 2022, to October 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like reimbursement for these 
services. 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 dental services provided by an out-of-network provider on October 4, 2022, to October 18, 2022.