Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for chiropractic manipulations provided from 
May 10, 2022, to June 20, 2022. 
 
You asked the Plan to provide reimbursement for the chiropractic manipulations. You say that you are 
requesting the Plan to provide payment directly to yourself. 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 50% 
coinsurance for each out-of-network Medicare-covered chiropractic visit.  
 
You have been asked to pay $20.23, which is 50% coinsurance of the allowed amount for the chiropractic 
manipulation on May 10, 2022 ($40.46 allowed amount x 50% coinsurance = $20.23). You have also been 
asked to pay $22.10, which is 50% coinsurance of the allowed amount for the chiropractic manipulation on June 20, 2022 ($44.20 allowed amount x 50% coinsurance = $22.10). These items/services fall within the 
chiropractic 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 provide reimbursement for chiropractic 
manipulations provided from May 10, 2022, to June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 24, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 an office visit provided 
on October 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left 
atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and 
interpretation (33340). 
 You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that enrollees must meet all criteria for coverage of a 
Percutaneous Left Atrial Appendage Closure (LAAC). 
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that at issue is the medical 
necessity of implanting a Left Atrial Appendage Closure (LAAC) device in this patient in whom there is 
elevated risk of thromboembolic stroke due to atrial fibrillation and elevated CHADS2VASC score. He 
tolerates anticoagulation, but sometimes forgets to take his medication. While there is reference to 
consideration of the LAAC, there is no documentation of performance of an evidence-based shared decision-
making. As such, guidelines would not support implantation of a LAAC in this setting. In summary, LAAC 
placement would not be considered reasonable or medically necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous transcatheter closure of the left atrial appendage with endocardial implant, 
including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage 
angiography, when performed, and radiological supervision and interpretation (33340).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MRI provided on December 09, 2021. 
 
You asked the Plan to pay for MRI. You say that you are requesting reconsideration. 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 MRI provided on 
December 09, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 06, 2022. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration. 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 home health services 
provided on July 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth (D7210), extraction, erupted 
tooth (D6104), and surgical placement of implant body (D6010) provided on September 19, 2022. 
 
You asked the Plan to pay for codes D7210, D6104 and D6010. You say that the Plan booklet states that dental 
implants are covered as part of the plan and covered as part of the $1,000 benefit. The Plan denied your 
request. The Plan says these services are not covered under the benefit package. 
 
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 an 
extraction, erupted tooth (D7210), extraction, erupted tooth (D6104), and surgical placement of implant body 
(D6010) provided on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7210) for tooth #16, #17, and #18 provided 
on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that there were 5 teeth covered on the pre-
determination so they all should be covered. 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 the Plan paid for 2 extractions on December 13, 2022, therefore, the dental benefit was exhausted on 
date of service December 13, 2022. Therefore, we decided that the Plan does not have to pay for the extractions 
(D7210) for tooth #16, #17, and #18 provided on December 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for aflibercept injections and the specialist 
office visits provided from October 17, 2022, to December 12, 2022. 
 
You asked the Plan to waive the cost sharing for the injections and office visits. You say that you are on a fixed 
income and cannot afford the payments. 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 Medicare Part B drugs. The contract also clearly says that you must pay a $35 copayment for 
vision services provided in a specialists office. 
 
You have been asked to pay $361.20, which is 20% coinsurance of the allowed amount for each injection 
($1,806 allowed amount x 20% coinsurance = $361.20). These items/services fall within the Medicare Part B drugs benefit category. You have also been asked to pay a $35 copayment for each specialist office visit. These 
items/services fall within the vision services benefit category. You have been asked to pay a total of $396.20 
($361.20 coinsurance + $35 copayment = $396.20). 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 
aflibercept injections and the specialist office visits provided from October 17, 2022, to December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the routine eyewear (V2020, V2100, V2784) provided 
on September 9, 2022. 
 You asked the Plan to pre-approve the routine eyewear. You say that you thought the eyewear would be 
covered. The Plan denied your request. The Plan says you have exceeded your frequency limit for routine 
eyewear. 
 
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 once every two years. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that routine eyewear was 
previously covered on September 3, 2021. The requested eyewear exceeds the Plans frequency limit. Based on 
this information, we decided that the Plan's rules for coverage of the routine vision services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the routine eyewear (V2020, V2100, V2784) 
provided on September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on July 23, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you are requesting reconsideration. 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 chiropractic care 
provided on July 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic film (D0330) and the extraction (D7210) for 
tooth #12 provided on December 31, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dental services should be covered under 
your medical benefit because you had to go to a surgeon. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because they are not covered by the Plan and do not fall under 
the enrollee's medical benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the panoramic film (D0330) and 
the extraction (D7210) for tooth #12 provided on December 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic labratory services provided on October 12, 2022. 
 
You asked the Plan to pay for genetic labratory services. You say that this was medically necessary and should 
be covered. 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 genetic labratory 
services provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 04, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. 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 office visit provided on 
November 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inhalation of nitrous oxide (D9230) provided on 
October 27, 2022. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because the 
inhalation of nitrous oxide is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
inhalation of nitrous oxide (D9230) provided on October 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portible chest xray provided on September 22, 2022. 
 
You asked the Plan to pay for a portible chest xray. You say that this was medically necessary and should be 
covered. You were having chest issues and needed this x-ray done. 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 a portible chest xray 
provided on September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic labratory services provided on June 30, 2022. 
 
You asked the Plan to pay for genetic labratory services. You say that this was medically necessary and should 
be covered. 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 genetic labratory 
services provided on June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on October 
04, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you say you cant afford the 
copayment. 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 $225 
copayment for outpatient surgery/Medicarecovered outpatient hospital facility visit. 
 
You have been asked to pay a $225 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicarecovered outpatient hospital facility visit benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an outpatient surgery provided on October 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT image capture (D0382) provided on July 19, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you feel that the Plan is not covering anything 
this year. 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 cone beam CT image capture (D0382) provided on July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), extraspinal chiropractic 
manipulative treatment (98943), and the manual therapy (97140) provided from January 10, 2022, through 
October 3, 2022. 
 
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 these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the therapeutic exercises (97110), extraspinal chiropractic manipulative 
treatment (98943), and the manual therapy (97140) provided from January 10, 2022, through October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that every action you took was completely necessary 
to get the correct treatment for you tooth abscess. 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 October 31, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on November 7, 2022.