Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne Liquid CDx testing (0239U) provided on 
December 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that FoundationOne Liquid CDx is a medically 
necessary laboratory test for patients with advanced stage, solid tumor cancer who have decided to seek further 
treatment. The Plan denied your request. The Plan says enrollees must receive their medical services from an 
in-network provider. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 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 FoundationOne Liquid CDx testing (0239U) 
provided on December 27, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite - one surface, posterior tooth 
#'s 19, 20 and 21 (D2391). 
 
You asked the Plan to pre-approve the dental services represented by code D2391. You say that the dentist told 
you that you need to prevent damage to the nerves in three teeth that will eventually occur as a result of 
receding gum tissue. You also say that his filling procedure will protect the nerves and prevent more serious 
and extensive work. The Plan denied your request. The Plan says the D2391 resin-based composite - one 
surface, posterior is not listed as 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
resin-based composite - one surface, posterior tooth #'s 19, 20 and 21 (D2391).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthodontic treatment (D8090). 
 
You asked the Plan to pre-approve the dental service. You say that you are a candidate for braces, and you have 
seen people your age with braces and the Plan should cover it for people over the age of 21. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because orthodontics 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 Plans 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 pre-approve 
orthodontic treatment (D8090).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3. 
 You asked the Plan to pre-approve Gelsyn-3. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gelsyn-3. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Monovisc, Orthovisc, Synvisc or Synvisc One. The documentation does 
not support that Monovisc, Orthovisc, Synvisc or Synvisc One would likely be less effective, and/or would 
likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gelsyn-3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
December 16, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you could not pick 
which provider you would see. 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 specialist physician/practitioner services. 
 
You have been asked to pay a $30 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner 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 the specialist office visit provided on December 16, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on November 15, 
2022. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. 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 outpatient mental 
health visit provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on November 01, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the records attached support the 
services provided. 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 domiciliary or rest home 
visit provided on November 01, 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 
February 6, 2023, to February 8, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not aware 
that you were responsible for 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 $300 
copayment each time you are admitted to an acute care hospital. 
 
 You have been asked to pay a $300 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient 
hospital stay provided from February 6, 2023, to February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
and crown - porcelain/ceramic (D2740) provided on January 4, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0220 and D2740. You say that you did 
not see this dentist on this date of service for the crown. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider.  Therefore, we decided that the Plan does not have to pay for an intraoral - periapical first radiographic image 
(D0220), and crown - porcelain/ceramic (D2740) provided on January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on December 
13, 2022. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that you would like to appeal the 
copayment for this procedure. 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 $200 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $200 copayment for the arthrocentesis. This item/service falls within the in-
network outpatient hospital 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. The records show the services were provided by an outpatient hospital facility. 
Therefore, we decided that the Plan does not have to waive the copayment for the arthrocentesis provided on 
December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abutment supported porcelain fused to metal crown (high 
noble metal)  (D6059) provided on June 9, 2022. 
 
You asked the Plan to pay for the abutment supported porcelain fused to metal crown. The Plan denied your 
request. The Plan says service D6059 is not included in the list of covered services. 
 
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 
abutment supported porcelain fused to metal crown (high noble metal)  (D6059) provided on June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 02, 2023. 
 
You asked the Plan to pay for lab 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 lab services provided on 
February 02, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the bladder examination provided on 
January 26, 2023. 
 
You asked the Plan to waive the copayment for the bladder examination. You say that you were told you would 
not have to make separate copayments. 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 $40 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $40 copayment for the bladder examination. 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 the bladder 
examination provided on January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the kidney disease treatment provided on 
January 31, 2023. 
 
You asked the Plan to waive the coinsurance for the kidney disease treatment. You say that you have been 
charged incorrectly. 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 services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for the kidney disease treatment. This item/service falls within 
the services to treat kidney disease 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 $56.94 ($284.70 allowed amount x 20% = $56.94). 
Therefore, we decided that the Plan does not have to waive the coinsurance for the kidney disease treatment 
provided on January 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen system provided on December 07, 2022. 
 
You asked the Plan to pay for a portable oxygen system. You say that you needed this oxygen system in order 
to leave your home. 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 portable oxygen 
system provided on December 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
January 25, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service 
because your dentist was not in the office, and they had to reschedule the appointment. 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 on the date of service of April 27, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
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 November 22, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
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 November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 
13, 2023. 
 
You asked the Plan to waive the copayment for the urgent care visit. 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 $50 
copayment for urgently needed services. 
 
You have been asked to pay a $50 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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 the urgent 
care visit provided on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health care services provided on 
December 16, 2022. 
 
You asked the Plan to waive the copayment for the mental health care services. You say that you were only 
there for monitoring or changing drugs. 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 outpatient mental health care. 
 
You have been asked to pay a $25 copayment for the mental health care services. 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 record shows this claim was approved and you are responsible for the cost 
share amount. Therefore, we decided that the Plan does not have to waive the copayment for the mental health 
care services provided on December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - mandibular (D5120) provided on 
February 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you don't understand why you can't use your 
$1,000 for the dentures. The Plan denied your request. The Plan says your benefit for the requested item $1,000 
dollar limit was met. 
 
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 complete denture - mandibular was met with the same claim for date of service 
February 3, 2023, allowing a payment of $1,000 for procedure codes D0140, D0220, D0230, D0270, D0330, 
and D5110, and denying D5120 for benefit maximum met. Therefore, we decided that the Plan does not have 
to pay for a complete denture  mandibular D5120 provided on February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9367 billed for date of service May 27, 
2022, to June 2, 2022. 
 
You asked the Plan to pay for procedure code S9367. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9367 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9367 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9367 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9367 billed for date of service May 27, 2022, to June 2, 2022.