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

 
We decided that the Plan does not have to pay for levocarnitine and a vitamin B-12 injection provided on July 
6, 2023. 
 
You asked the Plan to pay for levocarnitine and a vitamin B-12 injection. You say that the claim should be 
reprocessed  The Plan denied your request. The Plan says levocarnitine and a vitamin B-12 injection are 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 pay for levocarnitine and a vitamin B-12 injection. 
Our reviewer says that levocarnitine and a vitamin B-12 injection are not medically necessary. Our physician 
reviewer found that the clinical value and effectiveness of vitamin B-12 and levocarnitine in the setting of knee 
pain have not been demonstrated in the literature. Also, levocarnitine and a vitamin B-12 injection are not 
FDA-approved. Additionally, the requested drugs are not supported by one of the major drug compendia or by 
clinical research. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of levocarnitine and a vitamin B-12 injection have not been met. Therefore, we 
decided that the Plan does not have to pay for levocarnitine and a vitamin B-12 injection provided on July 6, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown restoration services for tooth #14 (D2920) provided 
on June 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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 date of service December 3, 2022. 
Therefore, we decided that the Plan does not have to pay for crown restoration services for tooth #14 (D2920) 
provided on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, intraoral x-ray, and cleaning 
(D0220, D0120, D1110) provided on June 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the 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 a periodic oral evaluation, intraoral x-ray, and cleaning (D0220, D0120, D1110) provided on June 8, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment and implant supported crown 
provided on June 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial and feel they should be covered under your medical benefit. The Plan denied your request. The 
Plan says the services denied correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
prefabricated abutment and implant supported crown provided on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment; extraspinal provided 
on May 12, 2023. 
 
You asked the Plan to pay for the chiropractic manipulative treatment; extraspinal. You say that the service you 
received should be covered. The Plan denied your request. The Plan says this is not a covered chiropractic 
service. 
 
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. Non-Medicare covered routine visits and x-rays 
performed by a chiropractor are not covered out-of-network. 
 
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 the chiropractic manipulative treatment; extraspinal provided on May 12, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen concentrator and delivery, set up, and 
dispensing service purchased on August 5, 2022. 
 
You asked the Plan to pay for the portable oxygen concentrator and delivery, set up, and dispensing service. 
You say that you had to purchase the oxygen equipment because you have suffered for several years. The Plan 
denied your request. The Plan says the purchased oxygen equipment and delivery, set up, and dispensing 
service is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for a portable oxygen 
concentrator and delivery, set up, and dispensing service purchased on August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an intraoral x-ray and fixed partial denture sectioning 
(D9120, D0220) provided on May 9, 2023. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Coverage for the fixed partial denture sectionings denied correctly as they do not fall within your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, coverage for the fixed partial denture sectionings denied correctly as they do not fall within your 
dental benefits. Therefore, we decided that the Plan does not have to pay more for an intraoral x-ray and fixed 
partial denture sectioning (D9120, D0220) provided on May 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment of methadone (G2067) 
provided on May 10, 2023. 
 
  You asked the Plan to pay for the medication assisted treatment. You say that you are an approved Medicare 
facility, you participate with Medicare, and Medicare processes your claims for this code all the time. You also 
say that you would like this claim to be reprocessed and payment to be remitted for your services. The Plan 
denied your request. The Plan says the treating facility is not a Medicare-enrolled Opioid Treatment Program. 
The Plan also says that this code is bundled into the OTP payment to Medicare-enrolled Opioid Treatment 
Programs and must be billed by a Medicare-enrolled OTP. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. The rules also say that only an entity enrolled with 
Medicare as an OTP can bill these codes. 
 
We looked at the file and Medicare rules. The claim was billed by the rendering provider and not an OTP 
facility. Individual providers cannot bill for OTP services. Though evidence was submitted showing SAMHSA 
certification, there is no evidence that the provider is enrolled in the Medicare program. Based on this 
information, we decided that Medicare rules for coverage of the medication assisted treatment have not been 
met. Therefore, we decided that the Plan does not have to pay for the medication assisted treatment of 
methadone (G2067) provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on November 09, 
2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you are disputing the share cost. 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 $15 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for office visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits 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 office visit provided on November 09, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80053, 85025) rendered by the out-
of-network (OON) provider on May 30, 2023.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization.  
  
 
 
 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the laboratory services (80053, 85025) rendered by the out-of-network (OON) 
provider on May 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
December 23, 2022, through December 27, 2022.  
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for acute inpatient psychiatric hospitalization on December 17, 2022 with 
Schizoaffective Disorder Bipolar Type. Based upon the review of the records provided, it was not expected that 
this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal 
or homicidal ideation, or auditory and visual hallucinations. The enrollee was compliant with treatment while 
not showing any acute threats to safety. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates 
in question as she did not have dangerousness to self or others and was compliant with her treatment. The 
health plans denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to 
require inpatient mental health treatment beyond the date in question as she was not a danger to herself or 
others and did not have auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services were reasonably expected to improve the 
enrollees condition or were for the purpose of a diagnosis beyond the date in question. It did appear that the 
records were supervised and evaluated by a physician. Based upon the review of the records provided, the 
enrollee does not meet the criteria for coverage of the acute inpatient psychiatric hospital care provided from 
December 23, 2022 forward as this enrollee was not shown to be a danger to herself or others, did not have 
delusions, or auditory and visual hallucinations as noted. She was cooperative/compliant with treatment while 
not showing any threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric hospital care provided from December 23, 2022, through 
December 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the MRI scan (A9585, 82565, J2405, 
J2704, 01922, 99100) provided on May 16, 2023. 
 
You asked the Plan to reduce the copayment for the MRI scan (A9585, 82565, J2405, J2704, 01922, 99100). 
You say that you should have a copayment of $265. 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 your deductible is $750. Until you have paid the deductible amount, you must pay 
the full cost for most of your covered services.  
 
  The item or service you asked the Plan to reduce the copayment for falls within the What is your Plan 
deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which, until you have paid the deductible amount, you must pay the full cost for most of your 
covered services. This cost sharing is a contractual obligation that had not been met at the time of the  MRI 
scan (A9585, 82565, J2405, J2704, 01922, 99100) was received on May 16, 2023. Therefore, we decided that 
the Plan does not have to reduce the copayment for the MRI scan (A9585, 82565, J2405, J2704, 01922, 99100) 
provided on May 16, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychological and neuropsychological testing provided on 
May 5, 2023. 
 
You asked the Plan to pay for psychological and neuropsychological testing. You say that the services were 
medically necessary. The Plan denied your request. The Plan says 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 
Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychological and neuropsychological testing provided on  
May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on June 7, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for a psychotherapy visit. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says an authorization was not obtained prior 
to the services 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 a psychotherapy visit provided on June 7, 2023, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for progressive lenses (V2781), polycarbonate lenses 
(V2784), and anti-reflective coating (V2750) provided on May 25, 2023. 
 
You asked the Plan to reimburse for progressive lenses (V2781), polycarbonate lenses (V2784), and anti-
reflective coating (V2750). You say that your left eye is now fully healed after cataract surgery issues. You 
also say this prescription for glasses is now required. The Plan denied your request. The Plan says this service 
is not covered under your Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the lenses are standard lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one pair of standard lenses and 
frames every two years. The Plan rules also says that upgraded lenses are not covered. Based on this 
information, we decided that the Plan's rules for coverage of progressive lenses (V2781), polycarbonate lenses 
(V2784), and anti-reflective coating (V2750) have not been met. Therefore, we decided that the Plan does not 
have to reimburse for progressive lenses (V2781), polycarbonate lenses (V2784), and anti-reflective coating 
(V2750) provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit. 
 
You asked the Plan to pre-approve a specialist office visit. You say that this provider has been in-network in 
the past. You also say you do not want to start over with a new provider. The Plan denied your request. The 
Plan says the requested provider is not in-network. The Plan also says there are in-network providers who can 
perform this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays, bitewing x-rays, and cleaning (D0120, 
D0220, D0230, D0274, D1110) provided on February 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the 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 intraoral x-rays, bitewing x-rays, and cleaning (D0120, D0220, D0230, D0274, D1110) provided on 
February 2, 2023.