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

 
We decided that the Plan does not have to waive the copayment for orthopedic visits provided on August 07, 
2023, to September 18, 2023. 
 
You asked the Plan to waive the copayment for orthopedic visits. You say that you feel you do not owe these 
copayment due to unconventional healing. 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for orthopedic visits. 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. The total you owe is $60 ($30 x 2 visits = $60). 
Therefore, we decided that the Plan does not have to waive the copayment for orthopedic visits provided on 
August 07, 2023, to September 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on August 15, 2023. 
 
You asked the Plan to pay for the x-rays. You say that are requesting reconsideration stating the bitewing x-
rays were your annual x-rays. 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 7, 2023. 
Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on August 
15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refractions (92015) provided on October 17, 2022, to 
August 3, 2023. 
 
You asked the Plan to pay for the eye refractions. The Plan denied your request. The Plan says this service is 
not covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
 
 
 
 
 
 
 
 The services you asked the Plan to pay for are considered routine vision services. Therefore, we decided that 
the Plan does not have to pay for the eye refractions (92015) provided on October 17, 2022, to August 3, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee is 
receiving adequate wound care therapy and HBO may benefit healing and improve patients response to 
therapy. Hence, meets criteria for HBO therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have been met. Therefore, we decided that the Plan has to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician attendance and 
supervision (99183).  
 
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 the chronic care management services provided on July 31, 
2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the chronic care management services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee must use in-network providers and has no 
out-of-network benefits. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/service at issue. This service was not routine dental 
care. 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 the chronic care management services provided on July 31, 2023, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nuclear medicine SPECT (DaT) scan (78803) for the
enrollee.

You asked the Plan to pre-approve a nuclear medicine SPECT (DaT) scan. You say that these services are
medically necessary. The Plan denied your request. The Plan says that medical necessity has not been
established.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a nuclear medicine
SPECT (DaT) scan. Our Medical Director states that the enrollee was evaluated on June 15, 2023, for a
Medicare annual wellness visit. It is documented that the enrollee was "having issues with short-term memory
loss." The enrollee's neurological exam was "Non-focal". The enrollee was encouraged to take Coenzyme
Q10, vitamin B12 and folic acid for issues with short-term memory. A computed tomography (CT) scan of the
head was ordered to evaluate for structural central nervous system (CNS) lesions. "Consider neurology
evaluation pending results of CT." A neurological evaluation was performed on August 24, 2023. At that time,
the enrollee had no resting tremor, no action tremor, and no cogwheel rigidity. A magnetic resonance imaging
(MRI) of the brain and an electroencephalogram (EEG) were ordered. The EEG recording was normal. The
MRI impression was "Possible nonobstructive hydrocephalus" and "Moderate sequelae of chronic
microvascular ischemia and mild generalized volume loss." The clinical documentation does not support that
the requested DaT scan was medically reasonable and necessary for the enrollee in this case. Our Medical
Director found that the enrollee's condition does not meet criteria for coverage of a nuclear medicine SPECT
(DaT) scan.

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 nuclear medicine SPECT (DaT) scan have not been met. Therefore, we
decided that the Plan does not have to pre-approve a nuclear medicine SPECT (DaT) scan (78803) for the
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 5, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
September 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth or exposed root (D7140) provided 
on February 27, 2023. 
 
You asked the Plan to pay for extraction, erupted tooth or exposed root. You say that this should be covered. 
The Plan denied your request. The Plan says this is not a covered service. 
 
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 
extraction, erupted tooth or exposed root (D7140) provided on February 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on July 05, 2023. 
 
You asked the Plan to pay for the x-ray. You say that the services were treated as an emergency service. 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 x-ray provided on July 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the biopsy procedure provided on 
September 19, 2023. 
 
You asked the Plan to waive the copayment for the biopsy procedure. You say that you were told that you 
would have a $30 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 $275 
copayment for in-network outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $275 copayment for the biopsy procedure. This item/service falls within the in-network outpatient surgery, including services provided at ambulatory surgical centers benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the biopsy procedure provided on September 19, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2019 billed for date of service September 
18, 2023. 
 
You asked the Plan to pay for procedure code H2019. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code H2019 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2019 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code H2019 billed for date of service September 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye surgery provided on September 18, 2023. 
 
You asked the Plan to pay for the eye surgery. You say that you do not agree with the amount of cost share you 
were billed. 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 Tier 2 
25% coinsurance for each Medicare-covered visit at an ambulatory surgical center. 
 
  You have been asked to pay $404.29 for the eye surgery. The total amount allowed to be billed for the eye 
surgery provided on September 18, 2023, was $2,417.16. You have been asked to pay a $404.29 coinsurance, 
which is 25% of the total allowed amount. This item/service falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers 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 pay for the eye surgery provided on September 18, 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 on July 
14, 2023, to July 20, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not agree with 
paying 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 $289 
copayment for inpatient hospital care. 
 
You have been asked to pay a $289 copayment for the inpatient hospital stay. This item/service falls within the inpatient hospital care 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. You have been asked to pay a total of $1,734 for the inpatient hospital stay ($289 
copayment x 6 days = $1,734). Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient hospital stay provided on July 14, 2023, to July 20, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on February 6, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider type is not covered. 
 
The Plan must follow Medicare rules. The rules say that a Master of Social Work (MSW) is not eligible to 
participate in Medicare. 
 
We looked at the file and Medicare rules. The file shows that the provider is a MSW. This provider type is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the outpatient mental health 
services rendered on February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 
billed for May 24, 2023, to June 13, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (PCD) coded E0675 billed for May 24, 2023, to June 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography and computed 
tomography (PET/CT) scan.  
 
You asked the Plan to pre-approve the PET/CT scan. You say that the services are necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET/CT scan. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found in this case the enrollee is noted to 
have Parkinson's Disease and cognitive impairments. He is not readily noted to meet formal diagnostic criteria 
for either AD or FTD let alone both. PD can also contribute to cognitive impairments as well. In as much it 
cannot be independently concluded that the requested service would meet the base requirement of the NCD for coverage of this service. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography and computed tomography (PET/CT) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
September 21, 2023, to September 22, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the procedure was 
never completed. 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 $165 
copayment for inpatient hospital care. 
 
You have been asked to pay a $165 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care 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. You have been asked to pay a total of $165 for the inpatient hospital stay ($165 copayment 
x 1 day = $165). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on September 21, 2023, to 
September 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient clinic services provided on August 11, 2023. 
 
You asked the Plan to pay for outpatient clinic services. You say that you are requesting reconsideration for 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 outpatient clinic services provided on August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each psychotherapy visit provided on July 
07, 2023, to October 03, 2023. 
 
You asked the Plan to waive the copayment for each psychotherapy visit. You say that you were unable to 
drive to the doctors office. 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 $35 
copayment for outpatient mental health care. 
 
You have been asked to pay a $35 copayment for each psychotherapy visit. This item/service falls within the 
outpatient mental health care 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 $315 ($35 copayment x 35 visits = $315). Therefore, we decided that 
the Plan does not have to waive the copayment for each psychotherapy visit provided on July 07, 2023, to 
October 03, 2023.