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

 
We decided that the Plan does not have to pay for the office visit provided on March 06, 2023. 
 
You asked the Plan to pay for the office 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 office visit provided 
on March 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four units of procedure code 87481 rendered on May 11, 
2022. 
 
You asked the Plan to pay for the services. You say that the coding is correct. The Plan denied your request. 
The Plan says four units were billed, but the documentation only supports that three units were tested. 
 
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, the CPT Code Manual definition of code 87481 is "Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports that 
three units, not four, or CPT 87481 were tested in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for four units of procedure code 87481 rendered on May 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 66984 rendered on March 21, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not support a complex extracapsular cataract removal with insertion of 
intraocular lens prosthesis. 
 
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, the CPT Code Manual definition of code 66984 is "Extracapsular cataract removal with insertion 
of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration 
or phacoemulsification); without endoscopic cyclophotocoagulation." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the procedure report does not 
include sufficient documentation to support a complex cataract procedure. This procedure cannot be verified as 
there is insufficient documentation to verify complexity, and in this case there is a more appropriate code to 
report for service documented. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 66984 rendered on March 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on May 02, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you disagree 
with the copayment 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 a $170 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $170 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 
computed tomography (CT) scan provided on May 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and biopsy provided on January 24, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the office visit and biopsy. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit and biopsy provided on January 24, 
2023, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each occupational therapy (OT) visit 
provided on February 15, 2023. 
 
You asked the Plan to waive the copayment for each occupational therapy (OT) visit. You say that you do not 
understand the additional $30 charge and believe it is excessive. 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 rehabilitation services. 
 
You have been asked to pay a $30 copayment for each occupational therapy (OT) visit. This item/service falls 
within the outpatient rehabilitation 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 each occupational therapy (OT) visit provided on February 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics provided on April 06, 2023. 
 
You asked the Plan to pay for orthotics. You say that you believe the services are 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 orthotics provided on 
April 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transmitter for a continuous glucose monitor (CGM) 
(A9277) and sensor for a CGM (A9276). 
 
You asked the Plan to pre-approve a transmitter and sensor for a CGM. You say that you gave the enrollee 
FreeStyle sensor samples, but you cannot continue to supply those. You also say that you need the enrollee to 
get the Dexcom complete system or FreeStyle Libre sensors. The Plan denied your request. The Plan says 
under the Medicare guidelines the requested products coded as A9277 and A9276 are not covered since they do 
not meet the DME benefit category requirements. The Plan also says these are supplies and accessories 
associated with a non-durable medical equipment device. 
 
The Plan must follow Medicare rules. Medicare rules say that products coded as A9276, A9277, A9278, or 
A9279 will be denied as non-covered. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a transmitter and sensor for a CGM have not been met. Specifically, the Plan says that the 
requested codes for the CGM items are A9277 and A9276. Therefore, we decided that the Plan does not have 
to pre-approve a transmitter for a continuous glucose monitor (CGM) (A9277) and sensor for a CGM (A9276).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
performed at an outpatient hospital facility provided on April 10, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan performed at an outpatient 
hospital facility. You say that the tests were allowed by the Plan and you should not be responsible for 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 diagnostic tests. 
 
You have been asked to pay a $350 copayment for a computed tomography (CT) scan performed at an 
outpatient hospital facility. This item/service falls within the outpatient diagnostic tests 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 computed tomography (CT) scan performed at an 
outpatient hospital facility provided on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied claim. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve the dental services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 17, 2022, to 
November 15, 2022. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial.  
The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan follows Medicare rules. The rules say that the HHA must enter a date of admission matching the 
From date on the first period of care in an admission. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay 
for home health services provided on October 17, 2022, to November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning for Lower Left Quadrant, 
Lower Right Quadrant, Upper Left Quadrant and Upper Right Quadrant (D4341) and implant placement for 
tooth #28 and #30 (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the deep gum and root cleaning was exhausted on date of service May 20, 2022. 
Therefore, we decided that the Plan does not have to pre-approve deep gum and root cleaning for Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant and Upper Right Quadrant (D4341) and implant 
placement for tooth #28 and #30 (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard  hard appliance, full arch (D9944) 
provided on March 16, 2023. 
 
You asked the Plan to pay for the occlusal guard. You say that you grind your teeth at night very badly and that 
your jaw and temple hurt tremendously. The Plan denied your request. The Plan says this service is not covered 
under 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 pay for an 
occlusal guard  hard appliance, full arch (D9944) provided on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) 
and crown - porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve the core buildup and crown - porcelain/ceramic. You say that you are in 
constant pain and discomfort. You also say that you would like this to be taken seriously and approve the 
crowns needed. The Plan denied your request. The Plan says coverage for only the services listed on this 
schedule are covered by your dental benefits. Core build up and tooth crown services are not listed as 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 Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested  services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup, including any pins when required (D2950) and crown - porcelain/ceramic (D2740).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on December 22, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that the 
copayment applied is too high and you are on a fixed income. 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 $225 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $225 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 $172.96, which is less than the standard copayment for 
an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
imaging (MRI) provided on December 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 10, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this was an 
emergency and you were told you shouldn't have to pay. The Plan denied your request. The Plan says these 
services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 10, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on April 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to - pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the botulinum toxin type A Botox is for the treatment 
of sialorrhea. The Plan denied your request. The Plan says Botox is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that Botox 
is not medically necessary. Our physician reviewer found that Botox is not FDA-approved. Although Botox is 
supported by one of the major drug compendia or by clinical research, the use is not recommended in any of 
the compendia.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc procedure. 
 
You asked the Plan to pre-approve the procedure. You say that the enrollee has suffered from midline back 
pain. The Plan denied your request. The Plan says  the VIA Disc procedure 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 procedure. Our reviewer says that 
the VIA Disc procedure is not medically necessary. Our physician reviewer found that there are no compelling 
rational presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested VIA Disc procedure 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 the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the VIA Disc procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on March 16, 2022.  
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the PCR testing is considered unproven and 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 pay for the urine PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the standard of care for the evaluation of urinary incontinence is urinalysis with urine 
culture and sensitivity. The PCR testing is considered unproven and not medically necessary. The review has 
determined that the items/services at issue in this case were 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 the urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on March 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and the associated 
administration services provided on February 02, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs and the associated administration 
services. You say that you received the same procedure previously and did not have the same 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 (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 20% coinsurance for chemotherapy drugs and the associated administration 
services. 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. The total you owe is $399.85, which is 
20% of the allowed amount for chemotherapy drugs and the associated administration ($1,999.26 allowed x 
20% = $399.85). Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy 
drugs and the associated administration services provided on February 02, 2023.