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

 
We decided that the Plan does not have to pay for the outpatient clinic visit provided on February 20, 2023, to 
March 27, 2023. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that you are requesting reconsideration. 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 outpatient clinic visit 
provided on February 20, 2023, to March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services, a prefabricated post and core, intraoral 
x-ray, and crown for tooth #23 (D2950, D2750, D2954, D0220) provided on January 9, 2023, to February 21, 
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 crown and intraoral x-rays has 
already been exhausted. Coverage for the core buildup services or prefabricated post and cores 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, certain limitations apply. Coverage for 
the core buildup services or prefabricated post and cores denied correctly as they do not fall within your dental 
benefits. Additionally, the record shows your benefit for the crown and x-rays was exhausted on date of service 
January 9, 2023 (D0220) and February 2, 2023 (D2750 tooth #23). Therefore, we decided that the Plan does 
not have to pay for core buildup services, a prefabricated post and core, intraoral x-ray, and crown for tooth 
#23 (D2950, D2750, D2954, D0220) provided on January 9, 2023, to February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown for tooth #21 (D2740) provided on May 18, 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 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 crown 
for tooth #21 (D2740) provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a mandibular partial denture (D5214) provided on 
February 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 your dental maximum 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 February 9, 2023. 
Therefore, we decided that the Plan does not have to pay more for a mandibular partial denture (D5214) 
provided on February 9, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45385 billed with diagnosis codes K57.30 
and Q43.8 provided on March 8, 2023. 
 
You asked the Plan to pay for procedure code 45385. 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. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines.  
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes K57.30 and Q43.8 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for procedure code 45385 billed with diagnosis codes K57.30 and Q43.8 provided on March 8, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on March 07, 
2023. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI). You say that you are appealing the claim 
payment denial. 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 magnetic resonance 
imaging (MRI) provided on March 07, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
October 26, 2022. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that this is too 
expensive, and the doctor ordered the ambulance. 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 $360 
copayment for ambulance services. 
 
You have been asked to pay a $360 copayment for an in-network ambulance ride. This item/service falls within 
the ambulance 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 an in-
network ambulance ride provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the physician service. You say that you have been seeing this doctor for the 
last eight years. You say that you want to continue to see this provider. You also say that it is not right that you 
cannot see this provider since changing to the closed panel system. The Plan denied your request. The Plan 
says the requested provider is not in the Plan's network. 
 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a 
consultation to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dexamethasone tablet. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has multiple lumbar compression 
fractures. You also say that this requires a short-term steroid boost. The Plan denied your request. The Plan 
says the medication is not covered as a medical benefit under the Plan. 
 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. Therefore, we decided that the Plan does not have to pre-approve dexamethasone tablet.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a joint injection provided on February 02, 
2023. 
 
You asked the Plan to reduce the copayment for a joint injection. You say that you think that the copayment 
should be lower. 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 $325 
copayment for outpatient surgery in an outpatient hospital facility. 
 
You have been asked to pay a $325 copayment for a joint injection. This item/service falls within the outpatient 
surgery in an outpatient hospital facility 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. However, since the allowed amount is less than the standard copayment, 
you only owe $264.84. Therefore, we decided that the Plan does not have to reduce the copayment for a joint 
injection provided on February 02, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi. 
 
You asked the Plan to pre-approve Leqembi. You say that the request for Leqembi is medically necessary for 
the enrollee. The Plan denied your request. The Plan says  Leqembi is not medically necessary and has 
significant side effects with the risks outweighing the benefits in this enrollee who does not have a clear and 
definitive diagnosis of Alzheimer's disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Leqembi. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee is not enrolled in a clinical trial. 
The enrollee has a mini-mental state exam (MMSE) score of 29/30 and a Montreal cognitive assessment 
(MoCA) test of 27/30, both reflecting normal cognitive functions. Although recommended in the Food and 
Drug Administration (FDA) label requirements no positron emission tomography (PET) scan was performed to 
confirm the presence of amyloid plaque. A cerebrospinal fluid (CSF) study was performed, which has not been 
cleared or approved by the FDA and is of controversial significance. The review has determined that the 
documentation does not support that the Leqembi is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqembi have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 23, 2023, 
to March 24, 2023. 
 You asked the Plan to pay for the home health services as billed. 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 follows Medicare rules. The rules state that home health services under a plan of care are paid based 
on a 30-day period of care. Home Health Agencies (HHAs) submit a Notice of Admission (NOA) at the 
beginning of an admission and then submit one claim for each 30-day period of care. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
documentation submitted does not include any evidence to support that a NOA was submitted at the beginning 
of the initial 30-day period of care. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from February 23, 2023, to March 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 6, 2023, to 
March 7, 2023. 
 
You asked the Plan to pay for home health services. You say that you do not agree with the denial of payment. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 6, 2023. The NOA was not received by the Plan until April 7, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 6, 2023, to March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye examination provided on April 5, 2023. 
 
You asked the Plan to pay for a routine eye examination. You say that you were not aware that the service was 
not covered. The Plan denied your request. The Plan says you received routine vision exam services from an 
out of network provider, so they are not covered. 
 
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 examination is part of a routine vision. 
 
We looked at the file and the Plan's rules. The Plan rules also say that in-network routine eye examinations are 
covered once per calendar year. The Plan rules also say that out-of-network routine eye examinations are not 
covered. The record shows that your routine eye examination was received out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of a routine eye examination have not been met. 
Therefore, we decided that the Plan does not have to pay for a routine eye examination provided on April 5, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a cochlear implant provided on May 26, 
2022. 
 
You asked the Plan to waive the coinsurance for a cochlear implant. You say that you only had to pay for the 
fitting fee of $300 and paid this. 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 all other Medicare-covered DME items.  
 
 You have been asked to pay $571.08 coinsurance, which is 20% of the allowed amount for a cochlear implant 
($2,855.38 allowed amount x 20% coinsurance = $571.08). This item/service falls within the all other 
Medicare-covered DME items benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a cochlear 
implant provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided April 18, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental exam. 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 September 7, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided April 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an MRI provided on February 6, 2023.  
 
You asked the Plan to pay for an MRI. You say that your physician's office contacted the Plan and was told a 
prior authorization was not required. The Plan denied your request. The Plan says an authorization was not 
obtained prior to services rendered. 
 
The requested service in this case requires a prior authorization with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an MRI provided on February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for glucose monitoring device provided on March 26, 2023. 
 
You asked the Plan to pay for glucose monitoring device. You say that you are appealing the claim payment 
denial. 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 glucose monitoring 
device provided on March 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from July 13, 2021, to 
July 14, 2021, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
disagree that the diagnosis code is not supported. The Plan denied your request. The Plan says diagnosis code 
K85.90 is not supported, which resulted in a DRG change. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code K85.90, defined as acute pancreatitis, 
unspecified without mention of organ complication. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that the documentation 
does not support diagnosis code K85.90. Our physician reviewer found the enrollee had an isolated value of 
elevated lipase, which is not specific to pancreatitis alone.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from July 13, 2021, to July 14, 2021, at the DRG originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the joint survey and the knee x-ray provided on March 06, 
2023. 
 
You asked the Plan to pay for the joint survey and the knee x-ray. You say that you are requesting 
reconsideration of the denied claim based on medical necessity. 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 joint survey and the 
knee x-ray provided on March 06, 2023.