Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the dental services that are covered up to the $2,000 maximum. 
We decided that the Plan does not have to pre-approve surgical placement of an implant body (D6010) and 
prefabricated abutment (D6056).  
 
You asked the Plan to pre-approve the dental services. You say that you are having difficulty with eating and 
with chronic pain and irritation due to the loss of teeth. You say the reconstructive surgery would not be for 
cosmetic purposes but for functional purposes. The Plan says that these are non-covered services with Original 
Medicare. 
 
We decided that the Plan has to pre-approve the dental services that are covered up to the $2,000 
maximum.  
 
The contract says you receive a $2,000 allowance every calendar year for preventive and comprehensive dental 
services. Dental codes D5110, D5810, D5811, D5865 and D7140 are listed as covered services under the 
supplemental benefit plan. Therefore, we decided that the Plan has to pre-approve the dental services that are 
covered up to the $2,000 maximum.  
 
We also decided that the Plan does not have to pre-approve surgical placement of an implant body 
(D6010) and prefabricated abutment (D6056). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, surgical placement of an implant body 
(D6010) and prefabricated abutment (D6056) are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve these services. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
November 18, 2022. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you are unsatisfied 
with the the service. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room services. This item/service falls within 
the emergency 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. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
services provided on November 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cognitive assessment provided on February 28, 2023. 
 
You asked the Plan to pay for cognitive assessment. You say that the assisted living facility is responsible to 
obtain prior authorization for all patients. 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 cognitive assessment 
provided on February 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71046 rendered on October 30, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 71046 will not be reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 71046 is "Radiologic examination, chest; 2 views." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee had a 
ventriculoperitoneal (VP) shunt shunt series on 10/30/22. There is a separate report describing the course of the 
shunt catheter through the thorax. However, this portion of the exam would be included as part of the shunt series and is not a separate exam. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 71046 rendered on October 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general ophthalmological services provided on February 25, 
2023. 
 
You asked the Plan to pay for general ophthalmological services. You say that you are requesting a 
reconsideration of the denied charges. 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 general 
ophthalmological services provided on February 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on January 20, 2023. 
 
You asked the Plan to waive the copayment for ambulance. You say that not agree with copay being applied 
and the hospital nearby was not able to take member. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $200 copayment per trip, each way for Medicare-covered ground ambulance services. Covered 
ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate 
facility that can provide care if they are furnished to a member whose medical condition is such that other 
means of transportation could endanger the persons health or if authorized by the plan.  The enrollee has been asked to pay a $200 copayment for ambulance. This item/service falls within the 
ambulance service benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance on January 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on December 17, 
2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you could not get to the hospital 
without transport due to you having a seizure. 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 $220 
copayment for ambulance services. 
 
You have been asked to pay a $220 copayment for ambulance. This item/service falls within the ambulance 
services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance provided on 
December 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 02, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support 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 laboratory services 
provided on January 02, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 2 levels of diagnostic facet blocks. We decided that the Plan does 
not have to pre-approve 1 level of diagnostic facet blocks.  
 
You asked the Plan to pre-approve 3 levels of diagnostic facet blocks. You say that the services are necessary. 
The Plan says that based on the documentation provided, coverage criteria have not been met. 
 
We decided that the Plan has to pre-approve 2 levels of diagnostic facet blocks.  
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet certain 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 2 levels of diagnostic facet blocks. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the LCD utilization limit 
is 2 levels per session. There is no extra-ordinary circumstance detailed to suggest a third level must be 
performed at the same time. Therefore, only 2 levels are 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 the 2 levels of diagnostic facet blocks have been met. Therefore, we decided 
that the Plan has to pre-approve 2 levels of diagnostic facet blocks.  
 
We also decided that the Plan does not have to pre-approve 1 level of diagnostic facet blocks. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare rules say that Facet Joint Interventions are 
considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who 
meet certain 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 1 level of diagnostic facet blocks. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the LCD utilization 
limit is 2 levels per session. There is no extra-ordinary circumstance detailed to suggest a third level must be 
performed at the same time. Therefore, only 2 levels are 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 1 level of diagnostic facet blocks have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 1 level of diagnostic facet blocks. 
 
 
 
 
 
 
 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram provided on November 02, 2022. 
 
You asked the Plan to pay for the electrocardiogram. 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 electrocardiogram 
provided on November 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a smoking and tobacco use cessation counseling visit 
provided on January 15, 2023. 
 
You asked the Plan to pay for the smoking and tobacco use cessation counseling visit. The Plan denied your 
request. The Plan says inpatient hospital stays with the principal diagnosis of tobacco use disorder are not 
reasonable and necessary for the effective delivery of tobacco cessation counseling services.  The Plan must follow Medicare rules. Medicare rules say that inpatient hospital stays with the principal 
diagnosis of tobacco use disorder are not reasonable and necessary for the effective delivery of tobacco 
cessation counseling services. 
 
We looked at the file, the Plans rules and the Medicare rules. The file shows that the services were provided in 
an inpatient psychiatric facility with the principal diagnosis of tobacco disorder. Based on this information, we 
decided that Medicare rules for coverage of the smoking and tobacco use cessation counseling visit have not 
been met. Therefore, we decided that the Plan does not have to pay for a smoking and tobacco use cessation 
counseling visit provided on January 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 28, 
2023, through March 31, 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 the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
 
 
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented for a scheduled hysterectomy for post-menopausal vaginal bleeding 
following a diagnosis of endometrial adenocarcinoma based on the findings from a prior dilation and curettage 
procedure. The assessment revealed anemia but stable vitals, heart rhythm, and breathing status. The enrollee 
was treated with a blood transfusion and a laparoscopic hysterectomy which was uncomplicated. The post-op 
assessment revealed the enrollee as stable. Based on the enrollee being stable and undergoing a typically 
ambulatory procedure without an unstable condition or being at high risk for complication, it was not expected 
that the enrollee would require hospital services that would likely cross two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. 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 acute inpatient hospital care provided from March 28, 2023, through March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on November 23, 2022. 
 
You asked the Plan to pay for wound care. You say that you believe the services are 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 wound care provided on 
November 23, 2022.
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 
March 18, 2023, to March 20, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were never given a 
semi-private room. 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 $325 
copayment per day for days 1-5 of each in-network inpatient hospital stay. Your contract with the Plan also 
clearly says that you must pay a $0 copayment per day for any additional days of the same in-network inpatient hospital stay. 
 
You have been asked to pay a $325 copayment per day for days 1-2 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 
two or for the day you were discharged. You have been asked to pay a total of $650 ($325 copayment per day x 
2 days = $650). 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 
March 18, 2023, to March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 3, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service was not authorized. 
 
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 an office visit provided on February 3, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on February 09, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all patients. 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 home visit for 
evaluation provided on February 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 14, 2023. 
 
You asked the Plan to pay for office visit. 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 office visit provided on 
February 14, 2023.