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

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on April 12, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 Medicare Part B prescription drugs. 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 allowed amount for the prescription drugs is $384.92. You are 
being asked to pay $76.98 ($384.92 x 20% = $76.98). Therefore, we decided that the Plan does not have to 
waive the coinsurance for Medicare Part B prescription drugs provided on April 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services provided on May 5, 
2023. 
 
You asked the Plan to waive the copayment for the specialist services. You say that you should not have a 
copayment for the provider services. 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 $45 
copayment each specialist visit for Medicare-covered service.  
 
You have been asked to pay a $45 copayment for the specialist services. This item/service falls within the 
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. Therefore, we decided that the Plan does not have to waive the copayment for the 
specialist services provided on May 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment an injection of an eye drug (67028) and the 
scanning of a computerized ophthalmic diagnostic imaging (92134) provided from March 29, 2023, to June 22, 
2023. 
 
You asked the Plan to waive the copayment an injection of an eye drug (67028) and the scanning of a 
computerized ophthalmic diagnostic imaging (92134). You say that after receiving your usual treatment, you 
received an explanation of benefit (EOB) that was different than your previous nine visits with this provider 
dating back to February 23, 2021. You also say that you have been met with nothing but slow, inefficient 
responses from the Plan that have not put you past the billing due date. 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 for 
copayment for specialist office or outpatient facility visits for diagnostic procedures and tests. There is also a 
$30 copayment for therapeutic radiology services.  
 
You have been asked to pay a $15 for an injection of an eye drug (67028). An injection of an eye drug (67028) 
falls within the specialist office or outpatient facility visits for diagnostic procedures and tests benefit category. 
You have also been asked to pay a $30 copayment for the scanning of a computerized ophthalmic diagnostic 
imaging (92134). The scanning of a computerized ophthalmic diagnostic imaging (92134) falls within the 
therapeutic radiology 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 an injection of 
an eye drug (67028) and the scanning of a computerized ophthalmic diagnostic imaging (92134) provided from 
March 29, 2023, to June 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (A4239). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (A4239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual wheelchair provided on April 22, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the manual wheelchair. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says the item 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 manual wheelchair provided on April 22, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an outpatient surgery and self-administered drugs 
provided from May 1, 2023, to May 2, 2023. 
 
You asked the Plan to waive the cost for an outpatient surgery and self-administered drugs. You say that you 
are unable to afford 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 a $400 
copayment for surgery services performed at an outpatient hospital.  
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. 
 
You have been asked to pay a $579.59 copayment for an outpatient surgery and self-administered drugs. This 
total includes a $400 copayment for an outpatient surgery and $179.59 for self-administered drugs. The 
outpatient surgery falls within the 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. Therefore, we decided that the Plan does not have 
to waive the cost for an outpatient surgery and self-administered drugs provided from May 1, 2023, to May 2, 
2023.  
 
Benefits for an outpatient surgery and self-administered drugs may be available under Medicare Part D. 
Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal 
rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 25, 
2023, to May 26, 2023, by an OON provider.  
 
You asked the Plan to pay for the subsequent nursing facility care. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 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 subsequent nursing facility care provided on 
May 25, 2023, to May 26, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350), dental surface scan (D0801), and intraoral - periapical each additional radiographic image 
(D0230) provided on May 11, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0350, D0801 and D0230. You say that 
it is unfair for you to have to pay for x-rays without a cleaning. You also say that the doctors told you that they 
did not take the insurance after the x-rays were taken. The Plan denied your request. The Plan says your benefit 
for the intraoral - periapical each additional radiographic image has already been exhausted. The Plan also says 
there is no coverage for 2D oral/facial photographic image or 3D dental service scan. 
 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 2D oral/facial photographic image 
or 3D dental service scan are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for a 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), 
dental surface scan (D0801). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral - periapical each additional radiographic image was exhausted on date of 
service May 11, 2023. You already received the allowed frequency of intraoral radiographic image (X-ray)-
D0220 on the appealed claim. Therefore, we decided that the Plan does not have to pay for a 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350), dental surface scan (D0801), and intraoral - 
periapical each additional radiographic image (D0230) provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiogram (TTE) provided on May 8, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the echocardiogram. You say that this is supported in the records. The Plan 
denied your request. The Plan says enrollees must receive their care from 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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the transthoracic echocardiogram (TTE) provided on May 8, 
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 the comprehensive audiometry evaluation and the reflex 
threshold measurements provided on April 4, 2023, by an OON provider.  
 
You asked the Plan to pay for the comprehensive audiometry evaluation and the reflex threshold 
measurements. 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 comprehensive audiometry evaluation and the 
reflex threshold measurements provided on April 4, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation, and the psychological 
evaluation provided on March 28, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the psychiatric diagnostic evaluation, and the psychological evaluation. You say 
that these services were medically necessary. The Plan denied your request. The Plan says enrollees must 
receive their care from 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 
items/services 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 psychiatric diagnostic evaluation, and the 
psychological evaluation provided on March 28, 2023, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on May 26, 2023. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a skilled nursing facility 
visit provided on May 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on May 15, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are appealing the denial with supporting 
documentation. 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 home visit provided 
on May 15, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 0242U provided on February 9, 2023. 
 
You asked the Plan to pay for procedure code 0242U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the 
IRE information regarding its decision to deny coverage or payment. 
 
We looked at the file and the rules. The billed date of service was the date at which the testing was performed. 
The Plan has not shown that the date of service does not meet one of the exceptions. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for procedure code 0242U provided on February 9, 
2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation-per quadrant (D4921 x 2), the 
localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per 
tooth (D4381 x 4), and the resin-based composite-three surfaces, posterior for tooth number 12 (D2393) 
provided from May 9, 2023, through May 16, 2023. 
 
You asked the Plan to pay for these items/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 gingival irrigation and the localized 
delivery of antimicrobial agents provided are not covered under the supplemental dental policy. Additionally, 
the Plan says that you have exhausted the allowable dental benefit for coverage of the resin-based composite 
for tooth number 12 provided in this case.   
 
 
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 gingival irrigation and the localized 
delivery of antimicrobial agents provided are not among those covered under this benefit. Additionally, the 
maximum allowable dental benefit for the 2023 calendar year is $2,000. The Plan issued payment in the 
amount of $2,000 for dental services provided for this calendar year; therefore, you have exhausted the 
allowable dental benefit for coverage of the resin-based composite for tooth number 12 provided in this case. 
Therefore, we decided that the Plan does not have to pay for the gingival irrigation-per quadrant (D4921 x 2), 
the localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per 
tooth (D4381 x 4), and the resin-based composite-three surfaces, posterior for tooth number 12 (D2393) 
provided from May 9, 2023, through May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided on April 3, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you had so much trouble with the denture you 
got a year ago, that you went back to the provider several times to adjust it. 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 October 25, 2021. 
Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided on 
April 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87798, 87653, 87640, 87181, and 87481) 
provided on February 26, 2023. 
 
You asked the Plan to pay for the panel testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the panel testing (87798, 87653, 87640, 87181, and 87481) provided on February 26, 2023.