Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic supplies provided on May 05, 
2023. 
 
You asked the Plan to waive the coinsurance for diabetic supplies. You say that you have received supplies 
previously and was not charged a 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 durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for diabetic supplies. 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. The total you owe is $132.16 ($660.81 allowed amount x 20% = 
$132.16). Therefore, we decided that the Plan does not have to waive the coinsurance for diabetic supplies 
provided on May 05, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on July 03, 2023. 
 
You asked the Plan to pay for nursing facility visit. 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 nursing facility visit 
provided on July 03, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5 (coagulation factor V) (eg, hereditary 
hypercoagulability) gene analysis, Leiden variant (81241). 
 
You asked the Plan to pre-approve F5 gene analysis. 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 F5 gene analysis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found per Medicare coverage guidelines, Genetic testing for the F2 and F5 genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for pregnant patients. In this case, you are not pregnant. In addition, there is no documentation in the 
clinical records that the testing will change medical management. The review has determined that the 
items/services at issue in this case are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of F5 gene analysis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden 
variant (81241).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on August 02, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration say that the COVID-
19 test and should be paid and you have submitted records for 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 lab testing provided on 
August 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy and the office visit provided on April 03, 2023. 
 
You asked the Plan to pay for the biopsy and the office visit. You say that you are requesting reconsideration of 
the denied claim. 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 biopsy and the office 
visit provided on April 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on March 15, 2023, 
to March 16, 2023. 
 
You asked the Plan to pay for the durable medical equipment. You say that you are requesting reconsideration 
of the denied claim. 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 durable medical 
equipment provided on March 15, 2023, to March 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for eyelid surgery services provided on April 
10, 2023. 
 
You asked the Plan to reduce the coinsurance for eyelid surgery services. You say that you were not aware that 
the provider was out-of-network. 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 40% 
coinsurance for out-of-network surgery services performed at an ambulatory surgical center. 
 
You have been asked to pay 40% coinsurance for eyelid surgery services. This item/service falls within the out-of-network surgery services performed at an ambulatory surgical center benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $541.68 
($1354.20 allowed amount x 40% = $541.68). Therefore, we decided that the Plan does not have to reduce the 
coinsurance for eyelid surgery services provided on April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 22, 2023. 
 
You asked the Plan to pay for an office visit. You say that you do not understand why the Plan isnt covering 
this. 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). there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility. Therefore, we decided that the Plan does not have to 
pay for an office visit provided on June 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for respiratory assist device provided on June 
09, 2023. 
 
You asked the Plan to waive the coinsurance for respiratory assist device. 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 50% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 50% coinsurance for respiratory assist device. 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. The total you owe is $154.40 ($308.79 allowed amount x 
50% = $154.40). Therefore, we decided that the Plan does not have to waive the coinsurance for respiratory 
assist device provided on June 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the new dentures are necessary because the 
current ones are ill-fitting. 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 you received a covered complete denture - maxillary (D5110) and complete denture - mandibular 
(D5120) on date of service March 30, 2023. Therefore, we decided that the Plan does not have to pre-approve a 
complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block of the right knee (64454). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not medically necessary.  
 
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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you were being treated for unilateral primary osteoarthritis of the right knee. You presented with 
increasing right knee pain. You have difficulty with standing, walking, or any kind of activity. The x-rays of 
the knee dated February 9, 2023 are noted to show that degenerative changes are present, severe laterally with 
bone-on-bone apposition; and atherosclerotic calcifications are seen in the soft tissues.   
 
 
The exam reveals tenderness to the right knee with pain on range of motion. You ambulate with a limp and a 
walker. However, there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
corroborate that the use of genicular nerve blocks are as safe and effective as standard treatment modalities. No 
compelling rationale is presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested genicular nerve block of the right knee is not medically 
reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block of the right knee (64454).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy provided on May 15, 2023. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare only 
for diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on May 25, 2023. 
 
You asked the Plan to pay for the annual wellness visit. You say that the service was medically necessary. The 
Plan denied your request. The Plan says an annual wellness visit was provided on April 7, 2023 and the benefit 
has been exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on  
May 25, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 10, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that you are requesting reconsideration stating you have 
a standing contract with the plan as an in-network provider and have had a contract since 04/2019. 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 April 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound, and a transthoracic 
echocardiogram (TTE) provided on April 04, 2023, to April 17, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound, and a transthoracic echocardiogram (TTE). You 
say that you cannot afford the copayment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment for other in-network diagnostic radiology services performed in an outpatient facility. 
 
You have been asked to pay a $175 copayment for an ultrasound, and a transthoracic echocardiogram (TTE). This item/service falls within the other in-network diagnostic radiology services performed in an outpatient 
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. 
The total you owe is $350 ($175 copayment x 2 services = $350). Therefore, we decided that the Plan does not 
have to waive the copayment for an ultrasound, and a transthoracic echocardiogram (TTE) provided on April 
04, 2023, to April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic consultation (D9310), a bone replacement graft 
for ridge preservation (D7953), and a guided tissue regeneration (D4266) provided on November 2, 2022. 
 
You asked the Plan to pay for D9310, D7953, and D4266. You say that this procedure was only 5 minutes 
long. The Plan denied your request. The Plan says the rendered dental services are not covered 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 
diagnostic consultation (D9310), a bone replacement graft for ridge preservation (D7953), and a guided tissue 
regeneration (D4266) provided on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral exam provided on June 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. 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 February 6, 2023, and 
April 25, 2023. Therefore, we decided that the Plan does not have to pay for an oral exam provided on June 28, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation, and physical therapy provided on 
June 01, 2023, to June 22, 2023. 
 
You asked the Plan to pay for the electrical stimulation, and physical therapy. You say that you are requesting 
reconsideration of the denied claim. 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 electrical 
stimulation, and physical therapy provided on June 01, 2023, to June 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 22, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. 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 laboratory services 
provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 07, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on June 07, 2023.