Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs medicaments dispensed in the office (D9630) 
provided on March 28, 2023. 
  
You asked the Plan to pay for the dental service. You say that you provided the proper documents, and you 
believe your claim should be approved. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the prescription drugs or pre-medications, whether dispensed or prescribed are 
not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the drugs 
medicaments dispensed in the office (D9630) provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #25 provided on April 19, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you thought all the services would be covered or 
you would not have gone with the treatment plan. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the core buildup is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #25 provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a Medicare Part B drug injection provided 
on April 24, 2023. 
 
You asked the Plan to waive the cost share for a Medicare Part B drug injection. You say that you disagree 
with the cost share applied. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $282.67 coinsurance, which is 20% of the allowed amount for a Medicare Part B 
drug injection ($1,413.34 allowed x 20% = $282.67). This item/service falls within the Medicare Part B 
prescription drugs 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 cost share for a Medicare Part B 
drug injection provided on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (00144) provided on April 06, 2023. 
 
You asked the Plan to pay for the anesthesia (00144). You say that the service 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 the anesthesia (00144) 
provided on April 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Zoll life vest (K0606) provided on 
April 04, 2023. 
 
You asked the Plan to waive the coinsurance for the Zoll life vest (K0606). You say that the item should be 
covered. 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 durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for the Zoll life vest (K0606). This item/service falls within the 
durable medical equipment (DME) 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 Zoll life vest (K0606) provided on April 04, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on May 05, 
2023. 
 
You asked the Plan to pay for a neuromuscular stimulator (E0745). You say that the item was 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 a neuromuscular 
stimulator (E0745) provided on May 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee requires non-invasive 
ventilation due to the severity of chronic respiratory failure secondary to COPD.  The Plan denied your request. 
The Plan says a home ventilator is not medically necessary for this patient because their needs can be met with 
an alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).   
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has extensive disease with associated chronic respiratory failure. There is no documentation other than a 
physicians opinion that the enrollee has failed BiPAP or BiPAP with AVAPS. However, there is 
documentation that shows the enrollee did not tolerate a trilogy ventilator. Therefore, the enrollee does not 
meet the LCD requirements for a ventilator. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an outpatient surgery provided on April 26, 
2023. 
 
You asked the Plan to waive the cost share for an outpatient surgery. You say that you disagree with the cost 
share. 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. Your 
contract with the Plan says that there is a $395 copayment after your $1000 deductible which applies to 
outpatient surgery.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient surgery benefit 
category. You are being asked to pay $233.64 towards your $1,000 deductible. The total amount you are being 
asked to pay is $628.64 ($233.64 + $395 = $628.64). The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $395 copayment after your $1000 deductible which applies to 
outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time an outpatient surgery was received on April 26, 2023. Therefore, we decided that the Plan does not have to waive the cost 
share for an outpatient surgery provided on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 22, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the Plan previously paid two claims for services 
rendered to the enrollee without any issues, payment of this claim should also be made. The Plan denied your 
request. The Plan says prior authorization was not obtained by the non-participating 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 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 22, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee has undergone other 
procedures with no pain relief. You say that the enrollee also has taken over the counter medications which has 
not been beneficial. The Plan denied your request. The Plan says the genicular nerve block is not medically 
necessary.  
 
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 the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found the genicular 
nerve block is the subject of ongoing clinical trials and is considered experimental.  
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on April 4, 
2023. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this procedure was free in the past. 
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 $20 
copayment for all other Medicare-covered diagnostic tests and procedures. 
 
You have been asked to pay a $20 copayment for the ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and 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 
copayment for the breast ultrasound provided on April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required for tooth 
number 13 (D2950) provided on April 3, 2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this dental item is not a covered benefit.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental item provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, 
including any pins when required for tooth number 13 (D2950) provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on November 15, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 Plan's 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 core 
buildup services (D2950) provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 4, 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 for payment. The 
Plan denied your request. The Plan says this provider is not 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 
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 May 4, 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 manual therapy (97140), an office visit (99203) and 
electrical stimulation (G0283) provided by a chiropractor on April 25, 2023, to April 27, 2023. 
 
You asked the Plan to pay for manual therapy, an office visit and electrical stimulation. You say that the 
chiropractic services should be covered due to your medical condition with your spine and sciatic nerves. The 
Plan denied your request. The Plan says that the only covered chiropractic service is manual manipulation of 
the spine. 
 
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. Therefore, we decided that 
the Plan does not have to pay for manual therapy (97140), an office visit (99203) and electrical stimulation 
(G0283) provided by a chiropractor on April 25, 2023, to April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 16, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting that the claim be reprocessed and 
paid in-network The Plan denied your request. The Plan says this provider is not 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 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 March 16, 2023, by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 23, 2022, to 
October 15, 2022. 
 
You asked the Plan to pay for home health services. You say that you say that updated plan information was 
sent. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home health services 
provided on September 23, 2022, to October 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that that a BiPAP or BiPAP with backup 
rate will not provide target tidal volumes that are needed to help the patient decrease the work of breathing. The 
Plan denied your request. The Plan says a home ventilator is not medically necessary for this patient because their needs can be met with an alternative device such as a BiPAP device with average volume-assured 
pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that although the 
patient has COPD and obesity hypoventilation syndrome (OHS) with chronic respiratory failure and 
component of thoracic restrictive disease, there is no documented trial of BiPAP or sleep study to determine if 
this modality, with or without AVAPS has been attempted or trialed in split night study. However, the 
documentation does support the need of some sort of ventilator but not sufficient to determine the home 
ventilator need. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 17, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that it is medically necessary. The Plan denied your 
request. The Plan says if the enrollee receives unauthorized care from an out-of-network provider, they may 
deny coverage and the enrollee will be responsible for the entire cost. 
 
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 April 17, 2023, by an 
out-of-network (OON) provider.