Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the records provided support 
the need for the services to be provided at the inpatient level of care.  The Plan denied your request. The Plan 
says that the enrollee is medically stable and has been provided medical clearance to undergo the approved 
elective procedure. The Plan says that there is no documentation provided to support that the expectation that 
the enrollee will require a greater than 2 midnight stay.  
 
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 an inpatient hospital admission. Our 
reviewer says that an inpatient hospital admission is considered medically reasonable and necessary in this 
case. Our physician reviewer found at the time of the request for an inpatient admission the requesting 
physician reasonably the enrollee's necessary hospital care would span two midnights. The enrollee was being 
treated for left shoulder rotator cuff arthropathy and bone-on-bone arthritis. She presented with left shoulder 
pain. The pain is constant and limits her. The exam reveals a decreased range of motion. Hawkins, Neers, 
drop arm test, and lift-off tests are positive. The enrollee is noted with a significant past and/or current medical 
history that would place her at increased risk for peri-surgical complications requiring an inpatient stay.  Her 
past medical history included anxiety, asthma, high blood pressure, chronic pain, depression, high cholesterol, 
and heart disease.  
 
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 inpatient hospital admission have been met. Therefore, we decided that the 
Plan has to pre-approve an inpatient hospital admission.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on October 20, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration for the services 
provided. 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 
October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and related services provided on October 10, 
2022. 
 
You asked the Plan to pay for an office visit, and related services. You say that these services were 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, and 
related services provided on October 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair umbilical hernia provided on December 09, 2022. 
 
You asked the Plan to pay for repair umbilical hernia. You say that the services were 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 repair umbilical hernia 
provided on December 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on December 19, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a skilled nursing facility visit. You say that you depend upon the facility staff to 
verify eligibility and to obtain authorization from the patients insurance. The Plan denied your request. The 
Plan says there was no preauthorization by a primary care provider (this is different than a referral) for an out-
of-network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a skilled nursing facility visit provided on 
December 19, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on February 01, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that the enrollee 
was told there was a mass and needed an MRI but there was no mass so the enrollee should not be responsible. 
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 $365 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $365 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 owed is $279.48, which is less than the standard copayment for an 
MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
image (MRI) provided on February 01, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on March 08, 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 March 08, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
November 1, 2022, to November 4, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that your discharge was 
delayed, and you should not have to pay for the whole stay. 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 per day for days 1-5 of each in-network inpatient hospital stay. Your contract with the Plan also clearly says you must pay a $0 copayment per day for days 6-90 of each in-network inpatient hospital stay. 
 
You have been asked to pay a $250 copayment per day for days 1-3 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been asked to pay after day 
three or for the day you were discharged. You have been asked to pay a total of $750 ($250 copayment per day 
x 3 days = $750). 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 inpatient hospital stay 
provided from November 1, 2022, to November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the heart rhythm review services provided 
on February 17, 2023. 
 
You asked the Plan to waive the copayment for the heart rhythm review services. You say that you did not go 
into the office, only emailed with the provider about results. 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 $10 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $10 copayment for the heart rhythm review services. This item/service falls 
within the specialist physician/practitioner 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. The record shows this claim was approved and you are 
responsible for the cost share amount. Therefore, we decided that the Plan does not have to waive the 
copayment for the heart rhythm review services provided on February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 the dental services on January 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Computed tomography (CT), thorax 
provided on March 15, 2023. 
 
You asked the Plan to waive the copayment for Computed tomography (CT), thorax. You say that you should 
not have to pay the billed amount because this was preventive health care. 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 $125 
copayment for diagnostic radiology. 
 
You have been asked to pay a $125 copayment for Computed tomography (CT), thorax. This item/service falls 
within the diagnostic radiology 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 $100.39. Therefore, we decided that the Plan does not have to waive the copayment for Computed 
tomography (CT), thorax provided on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided on January 2, 2023, by an out-
of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 You are requesting 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 pre-approve dental 
services provided on January 2, 2023, by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport and ground mileage provided on August 19, 2022. 
 You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage. You say that the submitted medical records support the medical necessity for ambulance transport. 
The Plan denied your request. The Plan says transportation to a physicians office is not a covered destination. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport and ground mileage provided on August 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral radiographic 
images (D0220), and resin-based composite (D2335) for tooth #8 provided on March 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reimburse you for the 
denied dental services. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the limited oral evaluation, intraoral radiographic images, and resin-based composite are not 
covered by the 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 a limited 
oral evaluation (D0140), intraoral radiographic images (D0220), and resin-based composite (D2335) for tooth 
#8 provided on March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for dental services coded as D0140 for December 23, 2022.
You asked the Plan to pay for these dental services. You say that these dental services should be covered by the
Plan. The Plan denied your request. The Plan says you were not enrolled in the dental coverage plan on
December 23, 2022.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a
dental benefit in excess of Medicare coverage, you were not enrolled in the additional dental benefit when
these services were provided. Therefore, we decided that the Plan does not have to pay for dental services
coded as D0140 for date of service December 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image and adjunctive pre-
diagnostic test (D0431, D0330) provided on February 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. Coverage for the adjunctive pre-diagnostic test denied correctly as it does 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. The record 
shows your benefit for the requested item or service was exhausted on date of service February 15, 2022. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image and adjunctive 
pre-diagnostic test (D0431, D0330) provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biologic materials to aid in osseous tissue regeneration 
(D4265), the guided tissue regeneration (D4266), the surgical placement of implant body (D6010), sinus 
augmentation (D7951), bone replacement graft (D7953), and anesthesia (D9239 and D9243) for tooth #1, #3, 
#5, and #20 provided on July 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for the 
anesthesia because it is covered under your dental coverage for the year of 2023. The Plan denied your request. 
The Plan says the denial of payment for these services is correct, because the biologic materials to aid in 
osseous tissue regeneration, the guided tissue regeneration, the surgical placement of implant body, sinus 
augmentation, bone replacement graft, and anesthesia are not covered by the 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 
biologic materials to aid in osseous tissue regeneration (D4265), the guided tissue regeneration (D4266), the 
surgical placement of implant body (D6010), sinus augmentation (D7951), bone replacement graft (D7953), 
and anesthesia (D9239 and D9243) for tooth #1, #3, #5, and #20 provided on July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0283 and 97140 provided on September 
13, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure codes G0283 and 97140 provided by an OON provider. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-
network care. 
 
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 procedure codes G0283 and 97140 provided on 
September 13, 2022, by an out-of-network (OON) provider.