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

 
We decided that the Plan does not have to pre-approve a hypoglossal nerve simulator. 
 
You asked the Plan to pre-approve a hypoglossal nerve simulator. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that hypoglossal nerve neurostimulation is considered 
medically reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea when all of 
the criteria listed in the Medicare rules section is met. 
 
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 hypoglossal nerve simulator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no report of 
sleep endoscopy or of CPAP intolerance. It appears the patient has had an increase in obstructive sleep apnea 
(OSA) symptoms despite regular use of CPAP. 
 
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 hypoglossal nerve simulator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a hypoglossal nerve simulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery, bone replacement graft, and biologic 
materials to aid in soft and osseous tissue regeneration (D4261, D4265, D4264, D4263) provided on December 
1, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as the claim was 
filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
   
The record shows that a claim for the dental services was not filed until December 8, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for osseous surgery, bone replacement graft, and biologic materials 
to aid in soft and osseous tissue regeneration (D4261, D4265, D4264, D4263) provided on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services (99490) provided on 
November 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chronic care management services. You say that the service was provided to 
the enrollee in good faith. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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. 
 
You not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no 
exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does 
not have to pay for the chronic care management services (99490) provided on November 25, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam provided on January 11, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical eye exam. You say that the enrollee was in a nursing home setting 
and could not choose a network provider. The Plan denied your request. The Plan says prior authorization was 
not obtained. 
 
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 did not pre-approve the 
medical eye exam. We found no exception that would require the Plan to pay for the medical eye exam. 
Therefore, we decided that the Plan does not have to pay for the medical eye exam provided on January 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluations (D0180 x 2) 
provided from March 3, 2022, to September 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a review of these services for 
payment. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
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 pay for the 
comprehensive periodontal evaluations (D0180 x 2) provided from March 3, 2022, to September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visits provided on 
September 30, 2022, and October 31, 2022 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that you did not have two 
telehealth specialist visits. 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 $35 
copayment for each Medicare-covered specialist visit.  
 
You have been asked to pay a $35 copayment for the specialist office visits ($35 copayment x 2 visits = $70). 
These items/services fall within the physician/practitioner services, including doctors office visits benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayments for the specialist office visits provided on 
September 30, 2022, and October 31, 2022
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on November 12, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
at an exhibition, fainted, and the event host called the ambulance. You also say that you consulted your doctor 
during this time, felt better after the intravenous fluids were given, and did not want to go to the hospital. The 
Plan denied your request. The Plan says since there was no transport, the ambulance charges are not covered. 
 
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 November 12, 2022. 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 with no 
transport (A0998) provided on November 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on November 7, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 service at issue is not manual manipulation of the spine. Office visits are not a 
covered benefit by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the office 
visit (99202) provided on November 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but is still somewhat unstable and should only 
require short-term additional acute care services that can safely be administered at the current facility until 
more appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
already available at the current facility. 
 
   
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires prolonged and 
intensive skilled services that are not available at a lower level of care. The Plan denied your request. The Plan 
says admission to the LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found all medically necessary care is being provided in the current acute care setting. There 
are no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 16, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this should have been 
included with the previous surgery. 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 $35 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner 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 the specialist office visit provided on November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bathtub seat. 
 
You asked the Plan to pre-approve a bathtub seat. You say that you are having surgery and the requested item 
will assist you while showering. The Plan denied your request. The Plan says this item is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that bath chairs are not covered because they are not 
primarily medical in nature.  
 
While a bathtub chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bathtub seat.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 09, 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 March 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015), scanning 
computerized ophthalmic diagnostic imaging (92134), and outpatient office visit (99204) provided on August 
10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vision services. You say that you feel these charges should be paid for the 
enrollee. The Plan denied your request. The Plan says these services were rendered by a non-network provider 
who does not work with the enrollees health plan, and the enrollee self-directed for care. The Plan also says 
the enrollee's primary care provider did not refer for services. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015), 
scanning computerized ophthalmic diagnostic imaging (92134), and outpatient office visit (99204) provided on 
August 10, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth occupational therapy visit 
provided on September 27, 2022. 
 
You asked the Plan to waive the copayment for a telehealth occupational therapy visit. You say that you should 
not be charged a copayment for the telehealth visit. 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 $40 
copayment for physician/practitioner service. 
 
You have been asked to pay a $40 copayment for a telehealth occupational therapy visit. This item/service falls 
within the physician/practitioner service 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 telehealth occupational therapy visit provided on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trifocal lenses provided on August 1, 2022. 
 
You asked the Plan to pay for the trifocal lenses. You say that you were confused about the rolling year portion 
of the benefit. You say you would hope there would be some leniency with this case. The Plan denied your 
request. The Plan says the benefit was exhausted.  
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 on a rolling calendar year since your last date of service. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid the $175 allowance toward lenses on 
August 3, 2021, which exhausted the benefit. Based on this information, we decided that the Plan's rules for 
coverage of the trifocal lenses have not been met. Therefore, we decided that the Plan does not have to pay for 
the trifocal lenses provided on August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the diabetic test strips provided on 
December 14, 2022. 
 
You asked the Plan to waive the coinsurance for the diabetic test strips. You say that you did not order these 
test strips. 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 in-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the diabetic test strips. This item/service falls within the in-
network durable medical equipment 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 coinsurance for the diabetic test strips provided on December 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiac ultrasound provided on 
November 07, 2022. 
 
You asked the Plan to waive the copayment for the cardiac ultrasound. You say that the scan was not done 
properly and you should not have to pay for it. 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 $155 
copayment for in-network outpatient radiological diagnostic services. 
 
You have been asked to pay a $155 copayment for the cardiac ultrasound. This item/service falls within the in-
network outpatient 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. Therefore, we decided that the Plan does not have to waive the 
copayment for the cardiac ultrasound provided on November 07, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis. 
 
You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that you should 
not be responsible to pay this because the nurse initially ordered the wrong CT scan. 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 $245 
copayment for advanced imaging service.  
 
You have been asked to pay $197.96 for a CT scan of the abdomen and pelvis. This is less than the standard 
amount. This item/service falls within the advanced imaging service 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 CT scan of the abdomen and pelvis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 02, 
2023. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you do not think you should 
be responsible for this 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 $50 
copayment for each Medicare-covered urgent care facility visit. 
 
You have been asked to pay a $50 copayment for an urgent care visit. This item/service falls within the each 
Medicare-covered urgent care 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 urgent care visit provided on January 02, 2023.