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

 
We decided that the Plan does not have to reduce the copayment for the lesion removal procedure provided on 
August 22, 2022. 
 
You asked the Plan to reduce the copayment for the lesion removal procedure. You say that you should only be 
charged for a specialist office visit. 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 
$185.35 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $185.35 copayment for the lesion removal procedure. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 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 $185.35. Therefore, we decided that the 
Plan does not have to reduce the copayment for the lesion removal procedure provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245), and a retainer crown (D6740) provided on 
June 13, 2023. 
 
You asked the Plan to pay for D6245 and D6740. You say that common dental procedures should be covered. 
The Plan denied your request. The Plan says the denied services are not covered 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 pontic 
(D6245), and a retainer crown (D6740) provided on June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWO) (E0483 x12). 
 
You asked the Plan to pre-approve an HFCWO. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries who meet specific criteria. 
 
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 HFCWO. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a high-frequency chest wall oscillation 
device is not medically necessary. Medicare does not cover a high-frequency chest wall oscillation device for 
the diagnosis of chronic obstructive pulmonary disease (COPD), because it has not been shown to be beneficial 
in the treatment of this disorder. 
 
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 HFCWO have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWO) (E0483 x12).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) (93702). 
 
You asked the Plan to pre-approve a bioimpedance spectroscopy. You say that this is medically necessary. The 
Plan denied your request. The Plan says bioimpedance devices for the detection of lymphedema are considered 
investigational. 
 
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 a bioimpedance spectroscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this form of testing is not standard of care and has limited high quality 
evidence to support its use in this type of clinical situation. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bioimpedance spectroscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) (93702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on May 16, 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. 
 
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 December 28, 2020. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on May 16, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction requiring bone removal (D7210) provided on 
June 29, 2023. 
 
You asked the Plan to pay for D7210. You say that there is a $0 copayment for extractions. The Plan denied 
your request. The Plan says D7210 is not a covered benefit. 
 
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 an 
extraction requiring bone removal (D7210) provided on June 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the blepharoplasty provided on May 4, 
2023. 
 
You asked the Plan to waive the cost sharing for the blepharoplasty. You say that you are now being billed by 
the provider an additional $750 for the surgery. 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 $750 deductible which applies to surgery services at an inpatient 
ambulatory surgical center. The Plan contract also says there is a $200 copayment which applies to surgery 
services at an in-network ambulatory surgical center. 
.   
The blepharoplasty you asked the Plan to waive the cost sharing for falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to surgery services at an inpatient ambulatory surgical center. You have also been asked to pay a $200 
copayment for the blepharoplasty. Specifically, the total allowed amount for the surgery was $1,259.80. The 
remaining amount was $509.80, after the deductible was applied. ($1,259.80 - $750 = $509.80). The $200 
copayment was applied to this remaining amount. 
 
This cost sharing is a contractual obligation that had not been met at the time the blepharoplasty was received 
on May 4, 2023. Therefore, we decided that the Plan does not have to waive the cost sharing for the 
blepharoplasty provided on May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arexvy. 
 
You asked the Plan to pre-approve Arexvy. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Arexvy. The Plan 
follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Arexvy. Therefore, 
we decided that the Plan does not have to pre-approve Arexvy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a guided tissue regeneration (D4266) and a bone replacement 
graft for ridge preservation (D7953) provided on May 8, 2023. 
 
You asked the Plan to pay for D4266 and D7953. You say that these services were needed because a simple 
extraction would not work. The Plan denied your request. The Plan says the denied dental services are not 
covered 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 guided tissue regeneration (D4266) and a bone replacement graft for ridge preservation (D7953) provided on May 8, 
2023.
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 January 3, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance responded, treated you and helped you get back on your feet. 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 January 3, 2023. 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 January 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization of artery of leg with angioplasty 
(37221, 37225, 37227). 
 
You asked the Plan to pre-approve revascularization of artery of leg with angioplasty. You say that this is 
medically necessary. The Plan denied your request. The Plan says this 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 revascularization of artery of leg with 
angioplasty. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the description of symptoms is insufficiently detailed to 
confirm that the enrollee is having lifestyle limiting walking distance due to claudication. There is no 
suggestion in the medical record that there is any limb threat. There does not appear to be an effort at 
conservative treatment. No ankle-brachial index is provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization of artery of leg with angioplasty have not been met. Therefore, 
we decided that the Plan does not have to pre-approve revascularization of artery of leg with angioplasty 
(37221, 37225, 37227).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) provided on March 31, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5298). You say that you shopped and found the best option 
for you was at this vendor. The Plan denied your request. The Plan says the hearing benefit is not covered if the 
services are not registered in advance and authorized. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when hearing aids are obtained through a Plan hearing vendor.  
 
 
  We looked at the file and the Plan's rules. The Plan rules say that for hearing aids you must obtain prior 
authorization from the Plan hearing. The Plan contract also says that hearing aids purchased outside of the Plan 
hearing are not covered. The record shows that you went out-of-network for the hearing aids. Based on this 
information, we decided that the Plan's rules for coverage of hearing aid (V5298) have not been met. Therefore, 
we decided that the Plan does not have to reimburse for hearing aids (V5298) provided on March 31, 2023.
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 April 5, 2023.  
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
doctor's office called for an ambulance because it is the hospital policy. You also say that you were fine and did 
not need to go to the hospital. 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 April 5, 2023. 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 April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified maxillofacial prosthesis (D5999) provided on 
November 28, 2022. 
 
You asked the Plan to pay for D5999. You say that this should be covered due to it being a medical issue. The 
Plan denied your request. The Plan says this service is not a covered benefit and is purely dental in nature. 
 
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 an 
unspecified maxillofacial prosthesis (D5999) provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and core buildup services (D2740, D2950) provided 
on January 4, 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. 
 
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 May 17, 2023, The claim 
for these services was received later and the benefit exhausted retroactively. Therefore, we decided that the 
Plan does not have to pay for a crown and core buildup services (D2740, D2950) provided on January 4, 2023.
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 March 22, 2023.  
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
physical therapist called 911 because your leg was a little swollen. You also say that the ambulance really did 
nothing for you and there was no need to go to the hospital. 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 March 22, 2023. 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 March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) and the self-care home management 
training service (97535) provided on May 10, 2023. 
 
You asked the Plan to pay 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 pay for the office visit (99202) and the self-care home management training 
service (97535) provided on May 10, 2023.
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 March 19, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance was called because you fell and hit your head which caused a bleeding wound. You also say that 
since the wound was cleaned and bandaged you did not feel it was necessary to be taken to the emergency 
room. 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 March 19, 2023. 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 March 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (64633, 64634). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance. You say that this is medically necessary. The Plan denied your request. The Plan says the 
request is not medically necessary because the records show that the enrollee has had intraarticular facet 
injections, and records do not demonstrate that the enrollee has had medial branch blocks performed. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary not covered. Medicare rules also say that in order for thermal radiofrequency destruction of lumbar 
paravertebral facet joint nerves to be considered medically reasonable and necessary, patients must have had at 
least 2 MBBs, with each providing a consistent minimum of 80% sustained relief of primary pain. 
 
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 destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance. Our reviewer says that the enrollee does not meet 
criteria for coverage. Our physician reviewer found the coverage criteria is based on medial branch blocks not 
intra-articular injections. The LCD criteria is greater than 80% pain relief for each block. This was not achieved 
and therefore, the request is deemed not medically reasonable and 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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (64633, 64634).