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

 
We decided that the Plan does not have to pay for the computerized dynamic posturography sensory 
organization test (CDP-SOT) provided on August 18, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CDP-SOT. You say that the care provided was medically necessary and in 
good faith. The Plan denied your request. The Plan says there is minimal information provided regarding 
duration and nature of the enrollee's symptoms, and no clearly documented dizziness or vestibular dysfunction. 
The Plan also says that the clinical value and effectiveness of computerized dynamic posturography sensory 
organization test (CDP-SOT) in the setting of diabetic neuropathy have not been demonstrated in the peer-
reviewed literature. 
 
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 pay for the CDP-SOT. Our reviewer says that the 
computerized dynamic posturography sensory organization test (CDP-SOT) was not considered medically 
reasonable and necessary in this case. Our physician reviewer found that there is minimal information provided 
regarding duration and nature of the enrollee's symptoms, and no clearly documented dizziness or vestibular 
dysfunction. Our reviewer found that the clinical value and effectiveness of computerized dynamic 
posturography sensory organization test (CDP-SOT) in the setting of diabetic neuropathy have not been 
demonstrated in the peer-reviewed literature. Our physician reviewer also found that it was not medically 
necessary for the CDP-SOT to be rendered by an out-of-network (OON) provider. 
 
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 CDP-SOT have not been met. Therefore, we decided that the Plan does not 
have to pay for the computerized dynamic posturography sensory organization test (CDP-SOT) provided on 
August 18, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital visit provided from 
October 30, 2021, to November 1, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. 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 $250 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 
 You have been asked to pay a 5$00 copayment for 2 days of inpatient hospital care. ($250 x 2 = $500). 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 inpatient hospital visit provided from October 30, 2021, 
to November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the intraoral - periapical first 
radiographic image (D0220) and limited oral evaluation - problem focused (D0140) provided November 16, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the intraoral x-ray and limited oral exam. You say that 
the servicing provider was incorrectly identified, and the services should be processed as in-network. The Plan 
denied your request. The Plan says you have exceeded the frequency limit for the intraoral x-ray and the 
limited oral exam has processed correctly. 
 
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 covers the intraoral 
x-ray once per calendar year and oral exams twice per calendar year.  We looked at the file and Medicare rules. 
The claim was submitted with an OON provider. The Plan provided documentation showing that an intraoral exam was previously covered on March 23, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the intraoral x-ray has been exceeded. 
The Plan additionally provided documentation shows that the Plan covered 50% of the allowed amount for the 
limited oral exam. Therefore, we decided that the Plan does not have to provide additional payment for the 
intraoral - periapical first radiographic image (D0220) and limited oral evaluation - problem focused (D0140) 
provided November 16, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #20 and retainer crowns 
(D6750) for tooth #'s 19 and 21. 
 
You asked the Plan to pre-approve a pontic and retainer crowns. You say that you need your teeth fixed but the 
Plan only covers 1 upper or 2 lower adjacent teeth. The Plan denied your request. The Plan says these services 
do not meet criteria for medical necessity because the x-rays show you are missing other teeth and are 
requesting a posterior tooth. 
 
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 covers a pontic and 
retainer 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 a pontic and retainer crowns. Our 
reviewer says that given the plan criteria, there would be no necessity found for a posterior bridge. Our 
physician reviewer found the missing tooth is a posterior one and the criteria for coverage has not been met as 
only missing anterior tooth may be considered for replacement with a fixed bridge. Our reviewer also found 
that although the posterior bridge can be fabricated and function well, the Plan coverage criteria limits 
consideration of fixed bridges to the anterior region in limited circumstances. 
 
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 a pontic and retainer crowns have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pontic (D6240) for tooth #20 and retainer crowns (D6750) for tooth #'s 19 
and 21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid services (V5257, 99199) provided on June 
23, 2021. 
 
You asked the Plan to pay for the hearing aid services. You say that you cannot afford this cost and need to be 
reimbursed for these services. The Plan denied your request. The Plan says the provider in this case is not part 
of the specified routine hearing vendor network. Hearing aids are only covered when purchased through the 
specified vendor. 
 
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 received through the Plan's specified routine hearing vendor network. 
 
 
 
 We looked at the file and the Plan's rules. The hearing aid services were received from a provider who does not 
participate in the Plan's specified routine hearing vendor network. Based on this information, we decided that 
the Plan's rules for coverage of the hearing aid services have not been met. Therefore, we decided that the Plan 
does not have to pay for the hearing aid services (V5257, 99199) provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided December 14, 2021. 
 
You asked the Plan to pay for the complete series of x-rays. You say that you were told you were due for a new 
set of x-rays. The Plan denied your request. The Plan says this service is 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 
intraoral - complete series of radiographic images (D0210) provided December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) supply allowance 
(K0553) provided on December 11, 2021. 
 
You asked the Plan to pay for a CGM supply allowance. You say that the items are medically necessary. The 
Plan denied your request. The Plan says documentation submitted did not include a valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
We looked at the file and Medicare rules. The record does not contain a valid physician order. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Based on 
this information, we decided that Medicare rules for coverage of continuous glucose monitor have not been 
met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) supply 
allowance (K0553) provided on December 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0480, 80307, 83789) rendered by 
the out-of-network (OON) provider on September 18, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the drug testing services (G0480, 80307, 83789) rendered by the out-of-network 
(OON) provider on September 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and abutment 
supported porcelain fused to metal crown (D6060). 
 
You asked the Plan to pre-approve the prefabricated abutment and abutment supported porcelain fused to metal 
crown. You say that you are experiencing pain and would like these services to be reconsidered. The Plan 
denied your request. The Plan says these services are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated abutment (D6056) and abutment supported porcelain fused to metal crown (D6060).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010) and radiographic/surgical 
implant index (D6190). 
 
You asked the Plan to pre-approve the dental services. You say that if you knew the rules in advance you 
would have told the provider to refer you to an in network dentist. You say that these services should be 
covered. The Plan denied your request. The Plan says the requested dental 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 requested implant placement and 
radiographic/surgical implant index are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve implant placement (D6010) and radiographic/surgical implant index 
(D6190).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the office visit and Electrocardiogram 
provided on December 14, 2021. 
 
 
 You asked the Plan to waive the coinsurance for the office visit and Electrocardiogram. You say that this was 
an annual wellness exam and that there should be no cost to you. The Plan denied your request. The Plan says 
the services being charged were additional to the routine annual wellness exam, and the coinsurance amount 
charged 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for services obtained from a primary care provider or under certain circumstances, treatment by a 
nurse practitioner or physician's assistant or other non-physician health care professionals in a primary care 
provider's office (as permitted under Medicare rules), and 20% coinsurance for Medicare-covered radiological 
diagnostic services, not including X-rays.  
 
You have been asked to pay a total of $30.97 for the office visit and Electrocardiogram. $27.76 for the office 
visit (which is 20% of the Plans allowed amount, $138.80), and $3.21 for the Electrocardiogram (which is 
20% of the Plans allowed amount, $16.05). An office visit falls within the Physician/Practitioner Services, 
Including Doctors Office Visits benefit category, and Electrocardiograms fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for the office visit and Electrocardiogram provided on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection, expandable controller and 
expandable controller harness for the enrollee. 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that there is not a medical need to control these power options through the 
joystick. 
 
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 these items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. The patient has three power options of power tilt, recline and elevating leg rests on the approved wheelchair. The patient's upper extremity 
strength and function support that the patient can control any power options through their own switches. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of these items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection, expandable controller and expandable controller harness for the 
enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided by a 
network provider from September 28, 2021, to October 7, 2021. 
 
 
 You asked the Plan to waive the copayments for the physical therapy visits. You say that you were told that 
you met your maximum out-of-pocket amount  The Plan denied your request. The Plan says you have been 
asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for each in-network Medicare-covered physical therapy and speech-language therapy visit.  
 
You have been asked to pay a total of $96.47 for the physical therapy visits. The physical therapy visits fall 
within the Outpatient Rehabilitation Services benefit category. The record shows you have been asked to pay 
a $25 copayment for the September 28, 2021, September 30, 2021, and October 5, 2021, dates of service. You 
have been asked to pay $21.47 on October 7, 2021, because this is where you met your $3,000 maximum out-
of-pocket amount. 
 
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 copayments for physical therapy visits provided by a network provider 
from September 28, 2021, to October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on November 8, 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 office visit (99213) rendered by the out-of-network (OON) provider on  
November 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
December 13, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you spoke to a 
customer service representative before the procedure and were told you would not have to pay a copayment 
because the colonoscopy was a preventative procedure. You also say you were not told if a polyp was removed 
that you would have a 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 $300 
copayment for outpatient surgery at an outpatient hospital.  
 The medical record shows that polyps were removed during your colonoscopy on December 13, 2021. 
Therefore, the colonoscopy is considered diagnostic, and a cost share applies. You have been asked to pay a 
$300 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls 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 diagnostic colonoscopy provided on 
December 13, 2021.  
 
Your complaint about the insurance company giving you incorrect information is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional epidural steroid injection (64484).  
You asked the Plan to pre-approve an additional epidural steroid injection. You say that the requested service is 
a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for coverage 
of the requested services have not been met. 
 
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 an additional epidural steroid injection. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that transforaminal ESIs (TFESIs) involving a maximum of two (2) levels 
in one spinal region are considered medically reasonable and necessary.  It is important to recognize that most 
conditions would not ordinarily require ESIs at two (2) levels in one spinal region. Our review has determined 
that you do not meet criteria for an additional epidural steroid injection coded 64484. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional epidural steroid injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an additional epidural steroid injection (64484).