Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower limb prosthetic services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve lower limb prosthetic services. 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. This means you will have to pay the provider in full for the services furnished.  
 
 
 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
lower limb prosthetic services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of an implanted loop recorder (ILR). 
 
You asked the Plan to pre-approve the ILR replacement. You say that it is felt that replacing the ILR would be 
beneficial. The Plan denied your request. The Plan says ILR removal was approved; however, there is no 
medical necessity for replacement.  
 
The Plan follows Medicare rules. Medicare rules say that ILR may be considered medically necessary for 
enrollees with a history of unexplained syncope or cryptogenic stroke.  
 
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 ILR replacement. Our reviewer says 
that the requested ILR is not medically necessary in this case.  Our physician reviewer found the enrollee has 
had an ILR implanted since 2019 which is at the end of its battery life. The provider has recommended 
replacing the old one with a new device. 
 
In the absence of history of unexplained syncope or cryptogenic stroke, an implantable loop recorder is not 
likely to be beneficial to the enrollee. Additionally, more than 4 years of constant monitoring by the original 
device has revealed adequate information for any decision making in this individual.  
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 ILR replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve replacement of an implanted loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 4, 2023, to February 7, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you went back to the 
hospital due to being given the wrong medication previously. 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 $400 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says that you then pay a $0 copayment per day for any additional days of the same inpatient hospital stay. 
 
You have been asked to pay a $400 copayment per day for days 1-2 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged after day two 
or for the day you were discharged. You have been asked to pay a total of $800 ($400 copayment per day x 2 
days = $800). This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 4, 2023, to February 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the renal biopsy provided on September 28, 
2022. 
 
You asked the Plan to waive the copayment for the renal biopsy. You say that you should not have to pay for 
two biopsies. 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 outpatient surgery and other medical services provided at hospital outpatient facilities. 
 
You have been asked to pay a $245 copayment for the renal biopsy. This item/service falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities 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 renal biopsy provided on September 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on December 
07, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on December 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pain management services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the pain management services. You say that you have been seeing this 
provider for years. The Plan denied your request. The Plan says you must receive your 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the pain management services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (Percutaneous Vertebroplasty (PVP) or 
Kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no documentation of a trial of a 
back brace. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital observation services provided 
on January 26, 2023, to January 27, 2023. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that you cannot 
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 $350 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $350 copayment for the hospital observation services. This item/service falls 
within the outpatient hospital observation 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 hospital observation services provided on January 26, 2023, to January 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the mental health visits provided on 
January 3, 2023, and January 10, 2023. 
 
You asked the Plan to waive the coinsurance for the mental health visits. You say that you would like these 
services to be reprocessed at the in-network benefit level. 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 35% 
coinsurance for out-of-network mental health services.  
 
 
 You have been asked to pay $55.16, which is 35% coinsurance of the allowed amount for the mental health 
visit provided on January 3, 2023 ($157.61 allowed amount x 35% = $55.16). You have also been asked to pay 
$37.49, which is 35% of the allowed amount for the mental health visit provided on January 10, 2023 ($107.11 
allowed amount x 35% = $37.49). You have been asked to pay a total of $92.65 ($55.16 coinsurance + $37.49 
coinsurance = $92.65). This item/service falls within the outpatient mental health 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 coinsurance for the mental health visits provided on January 3, 2023, and 
January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0509 billed for date of service December 
10, 2022.   
You asked the Plan to pay for procedure code G0509. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code G0509 is bundled into 
payment for code 99291. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code G0509 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code G0509 billed for date of service December 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the collection and application of autologous blood 
concentrate product, bone replacement graft for ridge preservation, and therapeutic parenteral drugs (D9610, 
D7921, D7953, D9612). 
 
You asked the Plan to pre-approve 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 they do 
not fall within your dental 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 pre-approve the 
collection and application of autologous blood concentrate product, bone replacement graft for ridge 
preservation, and therapeutic parenteral drugs (D9610, D7921, D7953, D9612).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22513). 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 kyphoplasty. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of a trial of a back brace. More conservative measures are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on October 12, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you are requesting the submitted documentation 
be reviewed. 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 October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and cone beam computed 
tomography (CT) scan provided on February 22, 2023. 
 
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 they do not fall 
within your dental 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 a 
comprehensive oral evaluation and cone beam computed tomography (CT) scan provided on February 22, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy, and related services provided on August 
24, 2022. 
 
You asked the Plan to pay for physical therapy, and related services. You say that these services were 
medically necessary. 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 physical therapy, and 
related services provided on August 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on January 13, 
2023. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with 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 $325 
copayment for outpatient surgery/outpatient hospital facility. 
 
You have been asked to pay a $325 copayment for a colonoscopy. This item/service falls within the outpatient 
surgery/outpatient hospital facility 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 
colonoscopy provided on January 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laparoscopy procedure provided on 
October 17, 2022. 
 
You asked the Plan to waive the copayment for the laparoscopy procedure. You say that the surgery was 
medically necessary. 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $300 copayment for the laparoscopy procedure. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 laparoscopy procedure provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the drug injection and drug administration 
provided on January 25, 2023. 
 
You asked the Plan to waive the cost share for the drug injection and drug administration. You say that you 
were quoted an incorrect cost share amount. 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 Medicare Part B drugs. Your contract also clearly says that enrollees must pay a $250 copayment for in-network surgical services provided at an outpatient hospital. 
 
You have been asked to pay $408.93, which is 20% coinsurance of the allowed amount for the drug injection 
and drug administration ($2,044.64 allowed amount x 20% coinsurance = $408.93). This item/service falls 
within the Medicare Part B drugs benefit category. You have also been asked to pay $66.62, which is less than 
the standard $250 copayment for the drug administration services. This item/service falls within the outpatient 
hospital services benefit category. You have been asked to pay a total of $475.55 ($408.93 coinsurance + 
$66.62 copayment = $475.55). 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 share for the drug injection and drug 
administration provided on January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
We do not need proir auth for this service. 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 May 24, 2022.