Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each mental health visit provided on 
August 23, 2022, to December 12, 2022. 
 
You asked the Plan to waive the coinsurance for each mental health visit. You say that this provider is in-
network. 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 out-of-network outpatient mental health care. 
 
You have been asked to pay 50% coinsurance for each mental health visit. This item/service falls within the 
out-of-network 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. The records show this provider was out-of-network when services were 
provided. Therefore, we decided that the Plan does not have to waive the coinsurance for each mental health 
visit provided on August 23, 2022, to December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on November 15, 2022. 
 
You asked the Plan to pay for a rest home visit. You say that the services 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 a rest home visit 
provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology provided on July 05, 2022. 
 
You asked the Plan to pay for oncology. You say that the services 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 oncology provided on 
July 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic x-ray (D0330), 2D oral/facial photographic image 
(D0350), diagnostic casts (D0470), occlusion analysis (D9950), 2D cephalometric x-ray (D0340), 
comprehensive periodontal evaluation (D0180), extraction (D7140) and problem focused limited oral 
evaluation (D0140) provided from October 28, 2022, to December 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that your dental services should be covered under 
your medical benefit. The Plan denied your request. The Plan says these services are not covered by the Plan's 
dental or medical 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. Additionally, these services would not be covered under your medical 
benefit because they are not extractions to prepare the jaw for radiation treatments. Therefore, we decided that 
the Plan does not have to pay for panoramic x-ray (D0330), 2D oral/facial photographic image (D0350), 
diagnostic casts (D0470), occlusion analysis (D9950), 2D cephalometric x-ray (D0340), comprehensive 
periodontal evaluation (D0180), extraction (D7140) and problem focused limited oral evaluation (D0140) 
provided from October 28, 2022, to December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on January 20, 
2023. 
 
You asked the Plan to pay for principal care management services. You say that you did not have any input in 
choosing who would be the provider. 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 principal care 
management services provided on January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns on tooth #4 and 6 (D6751), a pontic on 
tooth #5 (D6241), and core build up on tooth #4 and 6 (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that your previous bridge fell out and needs to 
be replaced. The Plan denied your request. The Plan says your benefit for retainer crowns and a pontic has 
already been exhausted. The Plan also says that since the replacement bridge was denied there is no need for 
the requested core build up. 
 
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 a bridge was exhausted in June 2022. As the retainer crowns and pontic for a 
replacement bridge are not covered the requested core build up is not necessary. Therefore, we decided that the 
Plan does not have to pre-approve retainer crowns on tooth #4 and 6 (D6751), a pontic on tooth #5 (D6241), 
and core build up on tooth #4 and 6 (D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a heart catheterization procedure provided 
on December 08, 2022, to December 09, 2022. 
 
You asked the Plan to reduce the coinsurance for a heart catheterization procedure. You say that you think that 
the cost sharing should be lower. 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 surgery performed at an outpatient hospital facility. 
 
You have been asked to pay 20% coinsurance for a heart catheterization procedure. This item/service falls 
within the in-network surgery performed at an 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. The total you owe is $3066.45 
($15,332.24 allowed amount x 20% = $3066.45 rounded up). Therefore, we decided that the Plan does not have 
to reduce the coinsurance for a heart catheterization procedure provided on December 08, 2022, to December 
09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on December 14, 2022. 
 
You asked the Plan to pay for office visit. 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 office visit provided on 
December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on February 23, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that this service is supported in the 
records. 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 and 
related services provided on February 23, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each mental health visit provided on 
February 15, 2023, to March 08, 2023. 
 
You asked the Plan to waive the copayment for each mental health visit. You say that your primary care 
provider should have referred you to a provider that 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 $30 
copayment for outpatient mental health care. 
 
You have been asked to pay a $30 copayment for each mental health visit. 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. The total you owe is $90 ($30 copayment per visit x 3 visits = $90). Therefore, we decided 
that the Plan does not have to waive the copayment for each mental health visit provided on February 15, 2023, 
to March 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care services provided on December 09, 2022, to 
December 11, 2022. 
 
You asked the Plan to pay for observation care services. You say that the services 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 observation care 
services provided on December 09, 2022, to December 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 17, 2023, to January 19, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you received such poor 
care that you should not have to pay 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 $395 
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 stay. 
 
You have been asked to pay a $395 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 for the day you 
were discharged. You have been asked to pay a total of $790 ($395 copayment per day x 2 days = $790). 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 January 17, 2023, 
to January 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on October 27, 2022. 
 You asked the Plan to pay for ambulance services. You say that  The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on October 26, 2022. 
 
You asked the Plan to pay for office visit. 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 office visit provided on 
October 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the specialist office visits provided on 
November 10, 2022, and December 20, 2022, and the eye surgeries provided on December 5, 2022, and 
December 20, 2022. 
 
You asked the Plan to reduce the cost share for the specialist office visits and the eye surgeries. You say that 
this should be charged at the tier 1 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 a $25 
copayment for physician/practitioner services, including doctor's office visits. Your contract with the Plan also 
clearly says that you must pay 20% coinsurance for each Medicare-covered visit at an outpatient facility. 
 
You have been asked to pay a $25 copayment for each specialist office visit provided on November 10, 2022, 
and December 20, 2022. You have been asked to pay a total of $50 ($25 copayments x 2 services = $50). This 
item/service falls within the physician/practitioner services, including doctor's office visits benefit category. 
You have also been asked to pay 20% coinsurance of the allowed amount for the eye surgeries. These 
items/services fall within the outpatient surgery, including services provided at hospital outpatient facilities 
benefit category.  
 
Date of Service Item Allowed Amount 20% Coinsurance 
November 10, 2022 92083 $27.10 $5.42 
November 10, 2022 9213351 $31.92 $6.38 
November 10, 2022 9213651 $43.31 $8.66 
December 5, 2022 66180RT $2,381.68 $476.33 
December 5, 2022 66986RT $490.23 98.04 
December 5, 2022 00145P3 $193.50 $38.70 
December 20, 2022 R360RT $1,929.09 $385.81 
December 20, 2022 8561026 $4.29 $0.85 
December 20, 2022 00145QK 161.25 32.25 
December 20, 2022 00145QX 161.25 32.25 
 
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 reduce the cost share for the specialist office visits provided on November 10, 2022, 
and December 20, 2022, and the eye surgeries provided on December 5, 2022, and December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injection (ESI) (64483). 
 
You asked the Plan to pre-approve the ESI. 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 repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using SAME scale* for at least three months. 
 
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 ESI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no documentation provided indicating 
that the previous injection provided at least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline using the same scale for at least three months. 
 
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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the epidural steroid injection (ESI) (64483).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 90471 and 90715 provided on December 2, 
2022. 
 
You asked the Plan to pay for procedure codes 90471 and 90715. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 90471 is a packaged service due to being billed on the same claim as code 99283, 
which has a status indicator of V. Additionally, Medicare says that unconditionally packaged services are 
identified in the OPPS Addendum B with status indicator of N and these services are not paid separately since 
payment is included in the APC. Code 90715 is identified with a status indicator of N. Therefore, we decided 
that the Plan does not have to pay for procedure codes 90471 and 90715 provided on December 2, 2022.