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

 
We decided that the Plan has to waive the copayments for nursing facility care visits provided from March 7, 
2023, to March 15, 2023. 
 
You asked the Plan to waive the copayments for nursing facility care visits. You say that you were denied 
authorization for another facility and was advised the cost would be covered at the approved facility. The Plan 
denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that physician visits are covered services while the enrollee is admitted in a SNF.  
 
The Plan says you must pay a $35 copayment for a nursing facility care visit. Based on the Plan contract, 
however, physician/practitioner services are covered under the SNF benefit. Therefore, we decided that the 
Plan has to waive the copayments for nursing facility care visits provided from March 7, 2023, to March 15, 
2023.  
 
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 reduce the copayment for a magnetic resonance imaging (MRI) 
provided on April 13, 2023. 
 
You asked the Plan to reduce the copayment for a magnetic resonance imaging (MRI). You say that you are 
unable to afford the cost share applied. 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 $195 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $195 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 a magnetic resonance imaging (MRI) provided on April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology care to be provided by an out-of-network 
(OON) provider.  
 You asked the Plan to pre-approve oncology care. You say that your physician group does not have any 
medical oncologist within the group and has not redirected you to another oncologist. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan and you can be treated within the Plan 
network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
oncology care to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the injection provided on October 27, 2022. 
 
You asked the Plan to waive the cost share for the injection. You say that you should not be charged a 
coinsurance for 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 20% 
coinsurance for each in-network Medicare-covered Part B drug. 
  You have been asked to pay $137.74, which is less than the standard $176.56 coinsurance for the injection 
(882.80/allowed amount x 20% = $176.56). This item/service falls within the 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. 
Therefore, we decided that the Plan does not have to waive the cost share for the injection provided on October 
27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the acupuncture visits provided on July 14, 2022, to 
September 15, 2022. 
 
You asked the Plan to pay more for the acupuncture visits. You say that you did not receive the correct 
reimbursement amount, it was short by $300. 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 
copayment for each out-of-network Medicare-covered visit.  
 
  You have been asked to pay a total of  $300 for the acupuncture visits ($20 copayment x 15 visits = $300). This 
service falls within the acupuncture for chronic low back pain 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 more for the acupuncture visits provided on July 14, 2022, to September 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on May 9, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says there was no prior authorization requested before the services were 
rendered.  
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 the physician services provided on May 9, 2023, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has a 3-month history of low 
back pain. Positive straight leg raise on the left. No red flags indicated. X-rays showed multi-level mild 
degenerative changes. No conservative treatment such as physical therapy (PT) noted. The enrollee takes 
Ibuprofen and was given a single dose of Celestone in the emergency department (ED) 5 weeks ago. No 
follow-up after last encounter on July 26, 2023. No intervention planned at this point. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 1, 
2023, to February 25, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not aware you would be 
responsible for a copayment and thought the stay was 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 $0 
copayment for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $2,548 for a SNF stay ($196 per day x 13 days = $2,548). This item/service falls 
within the SNF 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 a SNF stay provided 
from February 1, 2023, to February 25, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary due to the 
enrollee's lab results and unexplained weight loss. The Plan denied your request. The Plan says that records do 
not show that results of a thorough workup failed to reveal the cause of your weight loss. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the 
CT scan is medically necessary. Our physician reviewer found the enrollee has a very complicated medical 
history which includes active rheumatoid arthritis and Hepatitis B. The enrollee's platelet count is elevated, and 
they are a diabetic. The amount of weight loss is not quantified due to difficulty in weighing the enrollee due to 
immobility. The request for CT is reasonable especially given the history of Hepatitis B and rheumatoid 
arthritis and their treatment with Methotrexate. The requested CT should be approved. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the abdomen and pelvis.  
 
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 for post and core in addition to crown, indirectly fabricated 
(D2952) provided on April 6, 2023. 
 
You asked the Plan to pay for the post and core in addition to crown, indirectly fabricated. You say that you 
needed a root canal. You also say that the reinforcing post was required because the amount of tooth structure 
remaining was insufficient to maintain the integrity of the core build up. The Plan denied your request. The 
Plan says there is no coverage for D2952 - post and core in addition to crown, indirectly fabricated. 
 
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 post and 
core in addition to crown, indirectly fabricated (D2952) provided on April 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete dentures - maxillary (D5110), and mandibular 
(D5120) provided on January 24, 2023. 
 
You asked the Plan to pay for the maxillary and mandibular dentures. You say that you were told you were 
covered for dentures and then you were told you weren't. You also say that you have a medical reason for 
needing them. The Plan denied your request. The Plan says there is no coverage for dentures. 
 
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 
dentures - maxillary (D5110), and mandibular (D5120) provided on January 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 13, 2023. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the home health services are not supported in the medical record. Specifically, the claim was 
billed with an invalid type of bill. Home Health PPS claims must be submitted with type of bill 0329. Based on 
this information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Arthrocentesis, aspiration and/or injection without ultrasound 
guidance provided on January 23, 2023. 
 
You asked the Plan to pay for Arthrocentesis, aspiration and/or injection without ultrasound guidance. You say 
that you are appealing the claim payment denial. 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 Arthrocentesis, 
aspiration and/or injection without ultrasound guidance provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections provided at an outpatient hospital 
facility provided on May 12, 2022. 
 
You asked the Plan to waive the copayment for injections provided at an outpatient hospital facility. You say 
that you do not agree with the cost share applied. 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 $280 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $280 copayment for injections provided at an outpatient hospital facility. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
total you owe is $105.94, which is less than the standard copayment for an outpatient hospital facility visit. 
Therefore, we decided that the Plan does not have to waive the copayment for injections provided at an 
outpatient hospital facility provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) provided on April 12, 2023. 
 
You asked the Plan to pay for the intraoral - periapical each additional radiographic image. You say that due to 
multiple circumstances you are asking for reconsideration. The Plan denied your request. The Plan says your 
benefit for the requested services 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 services was exhausted on date of service April 12, 2023. You received 
the allowed frequency of an intraoral x-ray (D0220) on the appealed claim.  Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional 
radiographic image (D0230) provided on April 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with DRG 190 rendered on 
September 6, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 190. 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 the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the documentation does not support a diagnosis code of J15.9, as the chest x-ray shows no signs of 
pneumonia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with DRG 190 rendered on September 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for deluxe frames (V2025), bifocal lenses (V2200), anti-
reflective coating (V2750) and a miscellaneous vision items (V2799) provided on March 21, 2023. 
 
You asked the Plan to reimburse for deluxe frames (V2025), bifocal lenses (V2200), anti-reflective coating 
(V2750) and a miscellaneous vision item (V2799). You say that you paid the doctor for the glasses. You also 
say that any reimbursement should be sent to you. The Plan denied your request. The Plan says the benefit Plan 
does not cover this out-of-network vision care service/material. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when services are received by an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers a $300 benefit toward the 
purchase and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). The Plan rules also 
say that any benefits received at a non-network optical provider are excluded from this benefit. Based on this 
information, we decided that the Plan's rules for coverage of deluxe frames (V2025), bifocal lenses (V2200), 
anti-reflective coating (V2750) and a miscellaneous vision items (V2799) have not been met. Therefore, we 
decided that the Plan does not have to reimburse for deluxe frames (V2025), bifocal lenses (V2200), anti-
reflective coating (V2750) and a miscellaneous vision items (V2799) provided on March 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the arm joint. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medical records do not show that you have attempted at least six weeks 
of conservative care. 
 
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. 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. 
Additionally, on exam you have full passive motion with no cracking sounds. The x-rays did not corroborate 
any significant pathology. There is no compelling rationale that is presented to support the medical necessity of 
this request as an exception. 
 
 
 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the arm joint.