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

 
We decided that the Plan does not have to waive the coinsurance for an in-network wound care supply 
provided on March 10, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network wound care supply. You say that you were not 
informed that you would be having this item sent home or that it would cost anything. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
The allowed amount of this item is $30.20, resulting in a coinsurance amount of $6.04 ($30.20 x 20% = $6.04). 
 You have been asked to pay a $6.04 coinsurance for an in-network wound care supply. This item/service falls 
within the durable medical equipment (DME) and related supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for an in-network wound care supply provided on March 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an in-network electrocardiogram (EKG) and a 
nuclear stress test provided on February 27, 2023. 
 
You asked the Plan to waive the cost for an in-network EKG and a nuclear stress test. You say that the provider 
told you this would be covered, why is there such a huge amount due? 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 $110 copayment for other outpatient diagnostic 
tests radiological diagnostic services, not including x-rays, and a 20% coinsurance for Medicare Part B 
prescription drugs and 20% coinsurance for outpatient diagnostic tests and therapeutic services and supplies. 
 
You had a $110 copayment + 20% coinsurance for Medicare Part B drugs and 20% for surgical supplies = 
$359.31 ($110 + $249.31 = $359.31).  
 
You have been asked to pay a $359.31 cost share for an in-network EKG and a nuclear stress test. This 
item/service falls within the other outpatient diagnostic tests radiological diagnostic services, not including x-
rays, Medicare Part B prescription drugs, outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost for an in-network electrocardiogram (EKG) 
and a nuclear stress test provided on February 27, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity.  
You asked the Plan to pre-approve Evenity. You say that the enrollee has osteoporosis and her low T-score put 
them at a very high risk for fracture. You say that the enrollee needs treatment with a bone builder such as 
Evenity. The Plan denied your request. The Plan says the step therapy requirements have not been met.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. If a Plan decides to apply step therapy requirements to Part B drugs, they must 
disclose that information in the ANOC and EOC documents. The Plan's contract does not indicate that it has 
implemented such criteria for certain Part B medications. 
 
We looked at your contract with the Plan. We did not see where the contract says that the Plan has decided to 
apply step therapy requirements to Part B drugs. This means that the Plan did not follow Medicare rules for 
disclosure of step therapy information. Therefore, we decided that the Plan does not have to pre-approve 
Evenity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) and the mechanical traction therapy 
(97012) provided on March 2, 2023. Additionally, the Plan does not have to waive the copayments for the 
chiropractic manipulative treatments (98940 x 2) provided on March 2, 2023 and March 6, 2023. 
  
 
You asked the Plan to pay for the office visit and the mechanical traction therapy. Additionally, you asked the 
Plan to waive the copayments for the chiropractic manipulative treatments provided. You say that you are 
requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says 
mechanical traction therapy and chiropractic office visits are not covered by Medicare or the Plan. 
Additionally, the copayments have been applied correctly to the Medicare-covered chiropractic services 
provided in this case.  
 
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 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 $20 
copayment for each Medicare-covered chiropractic visit.  
 
The records show that the mechanical traction therapy and the chiropractic office visit provided are not covered 
benefits by Medicare or the Plan. Additionally, you were asked to pay $40 ($20 copayment x 2) for the 
chiropractic manipulative treatments provided on March 2, 2023 and March 6, 2023 accordingly. 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 office visit (99202) and the mechanical traction therapy (97012) provided on 
March 2, 2023. Additionally, the Plan does not have to waive the copayments for the chiropractic manipulative 
treatments (98940 x 2) provided on March 2, 2023 and March 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), and provisional crown (D2799) provided on March 20, 2023, by an out-of-
network (OON) provider. 
 
  You asked the Plan to pay for the dental services. You say that this emergency dental work was rendered to you 
after you spoke with a Plan representative. You also say that there are no providers taking on new dental 
patients in your home state, and no one wants to accept your Plan's dental coverage. The Plan denied your 
request. The Plan says the dental services were received from an OON provider and are not covered by your 
supplemental benefits. The Plan also says the provisional crown is not a covered expense under your dental 
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. 
 
The record shows you received the requested dental services from an OON 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 OON provider. The Plan also provides no coverage for a provisional crown 
(D2799). The record also shows that you contacted the Plan on March 20, 2023, for assistance with using your 
flex savings card, but not to review benefits or to check contracted status for provider. Therefore, we decided 
that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral 
periapical x-ray (D0220), and provisional crown (D2799) provided on March 20, 2023, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 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 January 23, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
April 4, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 90662 and G0008 provided on October 17, 2022. 
 
You asked the Plan to pay for procedure codes 90662 and G0008. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for these services based on Medicare criteria. The Plan has not explained why the type of bill is 
incorrect or what type of bill would be appropriate based on Medicare guidelines. Therefore, we decided that 
the Plan has to pay for procedure codes 90662 and G0008 provided on October 17, 2022.  
 
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 pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine and the thoracic spine. 
 
You asked the Plan to pre-approve the MRI of the cervical spine and the thoracic spine. You say that the 
services are medically necessary. The Plan denied your request. The Plan says information to show why the 
services are necessary was not received in the medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI of the cervical spine and the 
thoracic spine. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found 
detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive 
conservative care measures is not evident. There are no examinations provided for review to corroborate any 
subjective or objective findings to support the need for advanced imaging. Moreover, there are no provided x-
rays of the cervical or thoracic spine. Therefore, the MRI is 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 the MRI of the cervical spine and the thoracic spine have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the 
cervical spine and the thoracic spine.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve basic life support, non-emergency ambulance transport 
(A0428) and ground mileage, per statute mile (A0425). 
 
You asked the Plan to pre-approve non-emergency ambulance transport and ground mileage. 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. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance transport 
and ground mileage. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the documentation does not support that other means of transport are contraindicated, or that the enrollee 
needs lifesaving and life-sustaining equipment that only an ambulance can provide. Documentation does not 
support that ambulance services are medically 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 non-emergency ambulance transport and ground mileage have not been met. Therefore, we decided that the Plan does not have to pre-approve basic life support, non-emergency ambulance 
transport (A0428) and ground mileage, per statute mile (A0425).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a dental extraction (D7210) provided on January 13, 
2023. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for a dental extraction (D7210) provided on 
January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scalings and root planings (D4342) 
provided on January 30, 2023, and February 8, 2023. 
 You asked the Plan to pay more for the scalings and planings. You say that you would like the decision to be 
reconsidered. 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, the Plan offers a $2,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on May 10, 2023, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay more for the periodontal scalings and root planings (D4342) 
provided on January 30, 2023, and February 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided from 
February 22, 2023, to February 27, 2023. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that you had already paid 
a large copayment like this for an inpatient stay. They kept moving you to different facilities. 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 $375 
copayment per day, for days 1 to 5 for inpatient hospital care.  
 
You were in the hospital for 5 days, resulting in a $1875 total copayment ($375 x 5 = $1875). 
 You have been asked to pay a $1875 copayment for an in-network inpatient 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. Therefore, we decided that the Plan does not have to waive the copayment for an in-
network inpatient stay provided from February 22, 2023, to February 27, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound provided on December 9, 2022, by an OON 
provider.  
 
You asked the Plan to pay for the ultrasound. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says this service is not covered when received out-of-
network. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that out-of-network outpatient diagnostic testing, including an ultrasound is not covered. 
 
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 the ultrasound provided on December 9, 2022, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power seat elevation feature (E2300) and electronic 
connection device (E2311) provided on September 21, 2021. 
 
You asked the Plan to pay for the power seat elevation feature and electronic connection device. You say that 
you were not advised that these services would not be paid until about a year after you took possession. The 
Plan denied your request. The Plan says these items are not eligible for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature. If a wheelchair has an electrical connection device 
described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or 
power standing feature, it will be denied as non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the power seat elevation feature and electronic connection device have not been met. The record 
also shows that you were advised on August 17, 2021, that these services would not be covered. Therefore, we 
decided that the Plan does not have to pay for the power seat elevation feature (E2300) and electronic 
connection device (E2311) provided on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery service provided on 
March 22, 2023, to March 24, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery service. You say that you did not receive 
therapy services while in the hospital. 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 $225 
copayment for outpatient surgery. 
 
You have been asked to pay a $225 copayment for an outpatient surgery service. This item/service falls within 
the outpatient surgery 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 $177.61, which is less than the standard copayment for an outpatient 
surgery service. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient 
surgery service provided on March 22, 2023, to March 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
March 13, 2023. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not think you 
should be responsible for 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 $110 
copayment for Medicare-covered emergency room visits. 
 
You have been asked to pay a $110 copayment for an emergency room visit. This item/service falls within the 
Medicare-covered emergency room 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. Therefore, we decided that the Plan does not have to waive the copayment 
for an emergency room visit provided on March 13, 2023.