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

 
We decided that the Plan does not have to waive the coinsurance for the remdesivir injection provided on 
January 02, 2023, to January 04, 2023. 
 
You asked the Plan to waive the coinsurance for the remdesivir injection. You say that you thought this 
injection would be fully covered. 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 20% 
coinsurance for in-network Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the remdesivir injection. This item/service falls within the in-
network Medicare Part B prescription drugs 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 $454.19 ($2,270.93 allowed amount x 20% = 
$454.19). Therefore, we decided that the Plan does not have to waive the coinsurance for the remdesivir 
injection provided on January 02, 2023, to January 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation provided on February 02, 2023, by an 
out-of-network (OON) provider.  
 
 You asked the Plan to pay for electrical stimulation. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 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 electrical stimulation provided on February 02, 
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 complete denture - maxillary (D5110) provided on February 
20, 2023. 
 
You asked the Plan to pay for complete denture - maxillary. 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 complete 
denture - maxillary (D5110) provided on February 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 61645 provided on July 13, 2022. 
 
You asked the Plan to pay for procedure code 61645. You say that the medical records support the billing of 
code 61645. The Plan denied your request. The Plan says the medical records do not support the billing of code 
61645. 
 
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 61645 is Percutaneous arterial transluminal mechanical 
thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, 
fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s). 
 
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 procedure code 61645. Our reviewer says that the medical records do not support the billing of code 61645. Our reviewer found the record does not state that a 
thrombectomy or thrombolysis was performed in an intracranial artery. There is mention of catheterization, but 
no treatment of a thrombus by any means. The record does not support the procedure in question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 61645 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 61645 provided on July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prodigy test strips, Prodigy control solution and TruePlus 
Twist Trividia Health lancets provided on January 4, 2023 by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the diabetic supplies. You say that the submitted medical records support the 
medical necessity. The Plan denied your request. The Plan says the out-of-network services were 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 Prodigy test strips, Prodigy control solution and 
TruePlus Twist Trividia Health lancets provided on January 4, 2023 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from 
January 16, 2022, to January 18, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you have been charged 
incorrectly. 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 per day, for days 1 to 5 and a $0 copayment per day, for additional days of in-network Medicare-
covered hospital care.  
 
 You have been asked to pay a $275 copayment per day, for days 1 to 2 of the inpatient hospital stay. You have 
been asked to pay a total of $550 ($275 copayment x 2 days = $550). You have not been charged for any 
additional days. 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 reduce the copayment for the inpatient hospital stay provided from January 16, 2022, to 
January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on January 03, 
2023. 
 
You asked the Plan to pay for skilled nursing facility services. 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 skilled nursing facility 
services provided on January 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950), pontics (D6245), and the retainer 
crowns (D6740) for tooth #3, #4, #5, and #6 provided on February 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that you called to verify if the dental bridge 
procedure would be covered, and you were told the Plan would cover the expenses. The Plan denied your 
request. The Plan says the denial of authorization for these services is correct because the core buildup, pontics, 
and the retainer crowns are not covered by the Plan. Also, it was verified with the call records that the proper 
dental information was given out and retainer crowns, core buildup, and pontics were never asked to verify 
dental coverage on. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950), pontics (D6245), and the retainer crowns (D6740) for tooth #3, #4, #5, and #6 provided on 
February 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
January 20, 2023. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that this was medically 
necessary. 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for the ambulance transportation. 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 the 
ambulance transportation provided on January 20, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on October 27, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit, and lab services provided on 
February 21, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit, and lab services. You say that the enrollee 
wishes to continue seeking services with this provider. 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 a hospital outpatient 
clinic visit, and lab services provided on February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on February 21, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not payable as they were rendered by 
an out-of-network provider.  
 
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 provided by the Plans select hearing aid vendor.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met.   
 
 
 
Specifically, the Plans contract states that hearing aids are covered only when provided by the Plans select 
hearing aid vendor. However, the hearing aids in this case were rendered by an out-of-network provider. 
Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) provided on February 21, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the positron emission tomography scan 
provided on August 30, 2022. 
 
You asked the Plan to waive the copayment for the positron emission tomography scan. You say that you 
cannot afford 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 $300 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $300 copayment for the positron emission tomography scan. This item/service 
falls within the 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 copayment for the positron emission tomography scan provided on August 30, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim upper denture (D5810) and an interim lower 
denture (D5811) provided on March 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you did not know there were specific codes for 
dentures until you saw the explanation of benefits. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the interim upper denture and the interim lower denture are not 
covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an interim 
upper denture (D5810) and an interim lower denture (D5811) provided on March 30, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on November 21, 2022. 
 
You asked the Plan to pay for ophthalmological services. You say that you are requesting the submitted 
documentation be reviewed. 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 ophthalmological 
services provided on November 21, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the cabazitaxel injection (J9043) provided on May 6, 2021. 
 
You asked the Plan to pay for the cabazitaxel injection. The Plan denied your request. The Plan says that more 
details are needed to determine if this charge is eligible for coverage. 
 
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. The records do not support the Plan's denial in this case. This means that the 
Plan has not provided a valid reason for denying payment of the cabazitaxel injection. It is the burden of the 
Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated. Therefore, we 
decided that the Plan has to pay for the cabazitaxel injection (J9043) provided on May 6, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the frames, the progressive lens, the anti-reflective 
coating, and the miscellaneous vision services provided on December 9, 2022. 
 
You asked the Plan to pay more for the vision items. You say that you had cataract surgery, and the Plan is 
supposed to cover post-surgery glasses. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. Please note, the Plan partially paid for the vision items by applying your $150 vision 
reimbursement. 
 
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 40% 
coinsurance for out-of-network Medicare-covered eyewear.  
 
 You have been asked to pay $409.8 which is 40% coinsurance for the vision items. The vision items fall within 
vison care benefit category. The record shows 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 more for the frames, the 
progressive lens, the anti-reflective coating, and the miscellaneous vision services provided on December 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided from September 
1, 2022, to September 30, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy (PT) services. You say that the therapy services were 
medically necessary and appropriate. The Plan denied your request. The Plan says services from nurse 
practitioner (NP) providers are not covered under open access unless preauthorized. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the physical therapy (PT) services provided from September 1, 2022, to 
September 30, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed with mattress (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the bed you have is hurting your 
wound. You also say that it is affecting your health. The Plan denied your request. The Plan says a total electric 
hospital bed is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed with mattress (E0265).