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

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) show spinal stenosis and slippage. The cause 
of the back pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 31, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
afraid to go to an emergency room. You also say that this was an emergency medical treatment and should be 
covered. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 31, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit and the electrocardiogram 
(ECG) provided by an in-network provider on September 6, 2022. 
 
You asked the Plan to waive the deductible for the office visit and the electrocardiogram (ECG). You say that 
you do not understand the cost sharing. 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 that there is a $500 deductible which applies to physician/practitioner services, 
including doctors office visits, and outpatient diagnostic tests and therapeutic services and supplies. 
 
 
 
 You have been asked to pay a $131.35 deductible for the office visit. This item or service you asked the Plan to 
waive the deductible for falls within the physician/practitioner services, including doctors office visits benefit 
category. You have also been asked to pay a $223.01 deductible for the electrocardiogram (ECG). This item or 
service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $500 deductible which applies to physician/practitioner services, including 
doctors office visits, and outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is 
a contractual obligation that had not been met at the time the office visit and the electrocardiogram (ECG) were 
provided on September 6, 2022. Therefore, we decided that the Plan does not have to waive the deductible for 
the office visit and the electrocardiogram (ECG) provided by an in-network provider on September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth, or exposed root (elevation and/or 
forceps removal) (D7140), osseous, osteo periosteal, or cartilage graft of the mandible or maxilla - autogenous 
or non-autogenous, by report (D7950) and bone replacement graft for ridge preservation - per site (D7953) 
provided on August 8, 2022, and October 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services you received should be covered 
because they were medically necessary. 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 extraction, erupted tooth, or exposed root (elevation and/or forceps removal) (D7140), osseous, osteo 
periosteal, or cartilage graft of the mandible or maxilla - autogenous or non-autogenous, by report (D7950) and 
bone replacement graft for ridge preservation - per site (D7953) provided on August 8, 2022, and October 17, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair resin partial denture base, maxillary (D5612) provided 
on December 9, 2022. 
 
You asked the Plan to pay for dental services. You say that you were not clear if the service was covered or 
not, so you should not have to pay the billed amount. The Plan denied your request. The Plan says this service 
is not covered under your 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. Repair resin partial denture 
base, maxillary (D5612) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5612 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for repair resin 
partial denture base, maxillary (D5612) provided on December 9, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 24, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services 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 psychotherapy provided 
on January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cervical post collar/occipital mandibular 
on February 08, 2023. 
 
You asked the Plan to waive the coinsurance for cervical post collar/occipital mandibular. You say that you 
want to appeal the amount being charged. 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 20% 
coinsurance for Medicare-covered equipment and supplies. The provider billed in the amount of $909 and the 
member discount is $201.21. $909 - $201.21 = $707.79. $707.79 x 20% = $141.56. Therefore, results in the 
total cost sharing amount of $141.56. 
 You have been asked to pay a 20% coinsurance for cervical post collar/occipital mandibular. This item/service 
falls within the durable medical equipment (DME) and related supplies 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 cervical post collar/occipital mandibular on February 08, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the iron sucrose injections provided from January 6, 
2023, to January 13, 2023. 
 
You asked the Plan to waive the coinsurance for the drug injections. You say that you should only have to pay 
the office visit copayments. The Plan denied your request. The Plan says that 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 that enrollees must pay 20% coinsurance for Medicare Part B drugs.  
 
According to Medicare, the injection (code J1756) is considered a packaged code and is not separately payable. 
This code is also excluded from the physicians free schedule. Therefore, we decided that the Plan has to waive 
the coinsurance for the iron sucrose injections provided from January 6, 2023, to January 13, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on December 01, 2022, to January 04, 
2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for office visits. You say that you are requesting reconsideration and asking for the 
documents to be reviewed. The Plan denied your request. The Plan says the enrollee must receive their care 
from a network provider (for more information about this, see Section 2 in Chapter 3). In most cases, care the 
enrollee receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 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 office visits provided on December 01, 2022, to 
January 04, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve dermatology services to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the dermatology services. You say that the services are medically necessary 
due to the rarity of the enrollee's condition. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the dermatology services. Our reviewer 
says that the records indicate that the care provided was medically necessary. Our physician reviewer found the 
enrollee requires specialized management by an expert who has additional expertise in this rare condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the dermatology services have been met. Therefore, we decided that the Plan 
has to pre-approve dermatology services to be provided by an out-of-network (OON) provider.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 27, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that someone 
in the train station called for the ambulance. You also say that your vitals were checked by the paramedics and 
declined the offer for the transport as you felt better. The Plan denied your request. The Plan says these services 
are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 27, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the drug injection and drug administration 
provided on December 12, 2022. 
 
You asked the Plan to waive the coinsurance for the drug injection and drug administration. You say that the 
provider exceeded the fee schedule for this injection. 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 in-network Medicare Part B drugs and drug administration.  
 
You have been asked to pay $193.44, which is 20% of the allowed amount for the injection ($967.20 allowed amount x 20% = $193.44). You have also been asked to pay $7, which is 20% of the allowed amount for the 
drug administration ($35.01 allowed amount x 20% = $7). You have been asked to pay a total of $200.44 
($193.44 + $7 = $200.44). These items/services fall within the Medicare Part B 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. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the drug injection and drug administration provided on 
December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental cleaning (D1110), periodic oral evaluation 
(D0120), and the topical application of fluorideexcluding varnish (D1208) provided on December 12, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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. 
 
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. 
Therefore, we decided that the Plan does not have to pay more for the dental cleaning (D1110), periodic oral 
evaluation (D0120), and the topical application of fluorideexcluding varnish (D1208) provided on  
December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206), and 
prophylaxis - adult (D1110) provided on February18, 2022. 
 
You asked the Plan to pay for the topical application of fluoride varnish and prophylaxis - adult. You say that 
the dental office did not participate with your plan but would submit the claim for you. 
 
 The Plan denied your request. The Plan says the claim submission exceeds the time limitation to file a claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the topical application of fluoride varnish and prophylaxis - adult was not 
filed until February 23, 2023. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for topical application of 
fluoride varnish (D1206), and prophylaxis - adult (D1110) provided on February18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the unlisted evaluation and management 
services (99499) provided from September 7, 2022, through October 10, 2022. 
 
You asked the Plan to issue reimbursement 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 these services are 
not a covered benefit. 
 
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.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue reimbursement for the unlisted evaluation and management services 
(99499) provided from September 7, 2022, through October 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment ambulance transport provided on June 30, 
2021. 
 
You asked the Plan to waive the copayment the ambulance transport. You say that you felt safer at the hospital 
as your wife was away on a trip. 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 $250 
copayment for ambulance services.  
 
 
 You have been asked to pay a $250 copayment for the ambulance transport. This 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 ambulance transport 
provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the denosumab injection and administration 
provided on June 2, 2022. 
 
You asked the Plan to waive the cost share for the injection and administration. You say that you were told you 
do not have to pay this bill. 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. Your contract with the Plan also clearly says that you must 
pay a $25 copayment for services obtained from a specialist. 
 
You have been asked to pay $199.58, which is 20% coinsurance of the allowed amount for the injection 
($997.92 allowed amount x 20% = $199.58). This item/service falls within the Medicare Part B prescription 
drugs benefit category. You have also been asked to pay a $25 copayment for the drug administration. 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 cost share for the denosumab injection and administration provided on June 
2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planning (D4342 x 2) 
provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that deep cleanings are a covered benefit. The Plan 
denied your request. The Plan says this service is not a covered benefit under your dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal scaling and root planning (D4342 x 2) provided on December 13, 2022.