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

 
We decided that the Plan does not have to waive the copayment for wound care on February 07, 2023, to 
March 28, 2023. 
 
You asked the Plan to waive the copayment for wound care. You say that you did not know about this $295 
copayment and thought it was $20. 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 $295 
copayment for each outpatient hospital facility visit. There were eight days. 8 x $295 = $2,360. Therefore, 
results in the total cost sharing amount of $2,360. 
 
 You have been asked to pay a $295 copayment for each wound care. This item/service 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 wound care on February 07, 
2023, to March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 06, 2023. 
 
You asked the Plan to pay for a home visit. You say that that the provider is in-network with the Plan. 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 home visit provided on 
February 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on January 06, 2023. 
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 home visit provided on 
January 06, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health visit provided on February 03, 2023, to 
March 03, 2023. 
 
You asked the Plan to pay for the mental health visit. You say that you are requesting reconsideration of the 
denied claim. 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 the mental health visit 
provided on February 03, 2023, to March 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0242U) provided on February 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (0242U) provided on 
February 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network finger injection provided on 
April 18, 2023. 
 
You asked the Plan to waive the copayment for an in-network finger injection. You say that you have always 
paid a smaller copayment for this service. This is too high. 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 $275 
copayment for outpatient hospital and observation service.  
 
You have been asked to pay the allowed amount of $263.07 which is less than the $275 copayment for an in-
network finger injection.  This item/service falls within the outpatient hospital and observation 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 an in-network finger injection provided on April 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on December 24, 2022. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that no one 
informed you that you would be going into this kind of room, or that you would have to pay this huge 
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 $0 
copayment or up to $1480 copayment for inpatient hospital care.  
 
 You have been asked to pay a $1480 copayment for an in-network acute inpatient stay. This item/service falls 
within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an in-network acute inpatient stay provided on December 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical bone growth stimulator. 
 
You asked the Plan to pre-approve an electrical bone growth stimulator. You say that the requested electrical 
bone growth stimulator is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for an electrical bone growth stimulator.  
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 electrical bone growth stimulator. 
Our reviewer says that the enrollee does not meet criteria for an electrical bone growth stimulator.  Our 
physician reviewer found the enrollee was being treated for displaced fracture of distal left femur. He presented 
having not really had any significant pain but has not made any real progress with therapy either. Exam reveals 
mild pain with palpation. Passive and active range of motion is well tolerated from 0-45. X-rays are noted to 
show improved appearance and acceptable alignment. 
 
However, serial radiographs showed healing. Additionally, current peer-reviewed literature indicates that 
further large, randomized, controlled trials are required to support the use of electrical bone growth stimulators 
in the treatment of long-bone non-unions. No compelling rationale is presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested electrical bone 
growth stimulator is not medically reasonable or necessary.  
 
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 electrical bone growth stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an electrical bone growth stimulator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 09, 
2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were advised by the facility 
that you would not have a 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 $150 
copayment for outpatient diagnostic test.  
You have been asked to pay a $150 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic test 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. The total you owe is $131.09, which is less than the standard copayment for a diagnostic radiology 
service. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided 
on January 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Go-Go Elite Traveller scooter (K0800). 
 
You asked the Plan to pre-approve a scooter. You say that you would like further mobility with having a power 
operated vehicle to attend various activities. The Plan denied your request. The Plan says there is no evidence 
that a walker or wheelchair cannot meet your community mobility needs. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Go-Go Elite Traveller scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 01, 2023, by an out-of-
network (OON) provider.  
 
 You asked the Plan to pay for an office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be 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 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 an office visit provided on February 01, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office visit, and the external 
electrocardiographic recording provided on April 12, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit, and the external electrocardiographic recording. You say that the 
enrollee was referred by their primary care provider (PCP). The Plan denied your request. The Plan says 
enrollees must receive their care from a network provider. 
 
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 
items/services 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 new patient office visit, and the external 
electrocardiographic recording provided on April 12, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on February 15, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that the companys providers have a contract with 
the facility and are the only providers that will treat the patients there. 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 nursing facility care 
provided on February 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facial feminization surgery. 
 
You asked the Plan to pre-approve facial feminization surgery. You say that the enrollee is significantly 
distressed by the incongruence of her appearance and her gender. The Plan denied your request. The Plan says 
this is not a covered surgery. 
 
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 facial feminization surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has gender dysphoria.  The record 
provided does not document the presence of functional impairment or that the requested service is for the repair 
of an injured or malformed body member. The record provided is insufficient to establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage 
criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facial feminization surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facial feminization surgery.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services. 
 
You asked the Plan to pay for home health services. You say that you needed these home health services. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pay for 
home health services provided June 2, 2023, to July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gas permeable contact lens (V2531). 
 You asked the Plan to pre-approve gas permeable contact lens (V2531). You say that the enrollee suffers from 
Keratoconus and will require rigid gas permeable or scleral contact lenses that are medically necessary. The 
Plan denied your request. The Plan says the member's Evidence of Coverage does not allow for a benefit over 
$200 for this type of service. 
 
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 a reimbursement for eyeglasses and/or contact lenses combined, but is limited to 
$200 every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say that the total reimbursement for eyeglasses and/or 
contact lenses combined is limited to $200 every two years. The record shows that the provider is asking for an 
annual fee of  $1,030. The record shows that while the Plan offers vision benefits beyond those afforded by 
Original Medicare, the coverage is limited to $200 expense every two years. Based on this information, we 
decided that the Plan's rules for coverage of contact lens gas permeable (V2531) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve gas permeable contact lens (V2531).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation-per quadrant (D4921 x 4) provided on 
January 27, 2023. 
 
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 covered under your 
supplemental dental policy.  
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival 
irrigation-per quadrant (D4921 x 4) provided on January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), an adult 
prophylaxis (D1110), a limited oral evaluation (D0140), an intraoral - periapical first radiographic image 
(D0220), core buildup (D2950), and a porcelain/ceramic crown (D2740) provided from September 14, 2022, to 
November 11, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were assured by the provider's office 
that the provider was a participating provider with the Plan in 2022. 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. The Plans coverage rules say 
that this benefit includes the requested item or service but is limited to a $1,000 dental coverage limit every 
year for non-Medicare covered preventive dental services and non-Medicare covered comprehensive dental 
services combined. The member is responsible for any amount above the dental coverage limit. The Plan 
contract also says that there is a 50% coinsurance for preventive and comprehensive dental services. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows that the provider is not in-network, therefore the 50% coinsurance applied to your services. The record 
also shows your benefit for the requested item or service was exhausted on date of service November 11, 2022. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), an adult 
prophylaxis (D1110), a limited oral evaluation (D0140), an intraoral - periapical first radiographic image 
(D0220), core buildup (D2950), and a porcelain/ceramic crown (D2740) provided from September 14, 2022, to 
November 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for teeth numbers 
8,9. 
 
You asked the Plan to pre-approve a porcelain/ceramic crown (D2740) for teeth numbers 8,9. You say that you 
need the crown in order to avoid future complications The Plan denied your request. The Plan says this service 
is not covered in your dental benefit. 
 
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 
porcelain/ceramic crown (D2740) for teeth numbers 8,9.