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

 
We decided that the Plan does not have to pre-approve an implant 
 
You asked the Plan to pre-approve an implant. You say that the service should be covered. The Plan denied 
your request. The Plan says you must obtain services through your assigned dentist. 
 
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 an 
implant
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
November 1, 2021, through November 2, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $250 per 
day, for days 1-3 and $0 per day, for days 4+ for inpatient hospital care.   
 
You have been asked to pay $250 ($250 copayment x 1 day) for the inpatient hospital care provided. This 
means that you have been asked to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
November 1, 2021, through November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (code D1110) and the fluoride treatment 
(code D1208) you received on November 30, 2021. 
 
You asked the Plan to pay for the dental cleaning and fluoride treatment. You say that you have gingivitis so 
you need to have cleanings every three months to prevent your gums from receding. The Plan denied your 
request. The Plan says you had exhausted your benefit for these dental services.  The Plan says that cleanings 
and fluoride treatments are only covered two times per year.  You already received covered cleanings and 
fluoride treatments on January 19, 2021, and April 19, 2021. 
 
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. The Plan's coverage rules 
explicitly state that cleanings and fluoride treatments are only covered twice per year.  This limitation exists 
regardless of the necessity of the services.
  
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 dental 
cleaning (code D1110) and the fluoride treatment (code D1208) you received on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial medical nutrition therapy (97802) billed for date of 
service August 19, 2021. 
 
You asked the Plan to pay for initial medical nutrition therapy. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because the claim at issue is a duplicate of a claim that has already been processed and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of initial medical nutrition therapy have not been met. Specifically, the Plan has documented that the 
claim at issue is a duplicate of a prior claim that has been processed and paid. Therefore, we decided that the 
Plan does not have to pay for initial medical nutrition therapy (97802) billed for date of service August 19, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy procedure provided on 
June 2, 2021, and November 12, 2021. 
 
You asked the Plan to waive the copayment for the cystourethroscopy procedure. You say that the services 
should be covered. 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 $350 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 You have been asked to pay a $661.18 copayment for two cystourethroscopy procedures. Cystourethroscopy 
procedures fall within the Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 
cystourethroscopy procedure provided on June 2, 2021, and November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), provided on 
November 10, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that the service should be covered with 
your allowance. The Plan denied your request. The Plan says you have exceeded the yearly maximum 
frequency allowed for this service. 
 
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. Specifically, records indicate you have already received this service 
twice for the Plan year. This means the benefit has been exhausted and you are responsible for the cost. 
Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), provided on 
November 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bladder irrigation procedure (51700) 
provided on August 30, 2021. 
 
You asked the Plan to waive the copayment for the bladder irrigation procedure. You say that the services 
should be covered. 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 $150 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $150 copayment for a bladder irrigation procedure, these procedures fall within 
the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 bladder irrigation procedure 
(51700) provided on August 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nerve conduction studies (95912) 
provided on August 19, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
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 $200 
copayment for in-network outpatient diagnostic tests.  
 
You have been asked to pay a $200 copayment for the in-network outpatient diagnostic tests provided. This 
means that you have been asked to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the nerve conduction studies (95912) provided 
on August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rib belt for use with a lumbar brace. 
 
You asked the Plan to pre-approve the rib belt. You say that you feel that this rib belt is required in order to 
treat your pain. The Plan denied your request. The Plan says the brace was approved, but the requested belt is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 rib belt. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the member is an 80-year-old with a medical history including spondylolysis of the lumbar region with 
chronic low back pain who is requesting authorization for a rib belt. They have received conservative care for theor 
pain including spinal cortisone injections. The medical provider has recommended weight loss, a home exercise program and a lumbar corset to assist with mobility and pain. 
 
There is no medical necessity for a rib belt given the lumbar-sacral orthosis will treat the member's medical 
condition effectively. 
 
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 rib belt have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a rib belt for use with a lumbar brace.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 26, 2022, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 26, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 

 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 care from March 
26, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of March 26, 2022, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond March 26, 2022, as they were not a danger to 
themself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollee's condition or for the 
purpose of diagnosis. 
 
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 care from March 26, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 26, 
2022, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an arthrocentesis injection (20610) 
provided on June 25, 2021. 
 
You asked the Plan to waive the cost-sharing for an arthrocentesis injection. You say that the services should 
be covered at a higher rate because it was a simple procedure that you haven't had to pay this much for before. 
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 $250 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 You have been asked to pay a $250 copayment for an arthrocentesis injection. Arthrocentesis injections fall 
within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 cost-sharing for an 
arthrocentesis injection (20610) provided on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with field of view of both jaws; with or without cranium (D0367) and extraction, erupted tooth or 
exposed root (elevation and/or forceps removal) (D7140) provided November 17, 2021. 
 
You asked the Plan to pay for the cone beam CT scan and tooth extraction. You say that these services were 
recommended by your dentist, and you assumed they would be covered. The Plan denied your request. The 
Plan says these services are not covered under your 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 the cone 
beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without 
cranium (D0367) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) 
provided November 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Geri recliner chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says this service is not covered by Medicare. 
 
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 pre-approve a Geri recliner chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), provided on October 21, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that the service should be covered. The Plan denied 
your request. The Plan says you have exhausted the Plan's benefit for this service. 
 
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. Specifically, records indicate you have already received this service 
twice for the Plan year. This means you have exhausted the benefit and are responsible for the cost. Therefore, 
we decided that the Plan does not have to pay for the prophylaxis (D1110), provided on October 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided September 9, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you would like the Plan to pay for the 
service. The Plan denied your request. The Plan says ambulance services are not covered when there is no 
transport.  
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 9, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided September 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aspen interspinous decompression at L4-5, L5-S1 for 
the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device is investigational in this clinical setting, as opposed to traditional open 
discectomy or minimally-invasive approaches. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this device is experimental in spine surgery. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aspen interspinous decompression at L4-5, L5-S1 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on June 22, 
2021. 
 
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 the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic imaging provided on December 
23, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic imaging. You say that the service provided was 
pre-authorized by the Plan and you should not owe the copayment amount. The Plan denied your request. The 
Plan says the service provided was approved and the proper copayment amount was applied. 
 
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 $275 
copayment for Advanced Imaging Services. The total amount allowed was $229.23 which is less than the 
copayment amount of $275. Therefore, only $229.23 was charged as the copayment amount for this service. 
 
  You have been asked to pay a $229.23 copayment for the diagnostic imaging. The diagnostic imaging 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 
diagnostic imaging provided on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth provided on March 29, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the telehealth. You say that the enrollee had a previous visit, and the claim was 
paid so this one should be paid too. The Plan denied your request. The Plan says the rendering provider is an 
out-of-network provider and there was no approved authorization. It was also determined that the previous 
claim that was paid was due to an administrative error. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a telehealth provided on March 29, 2021, by an 
out-of-network (OON) provider.