Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation services from residence to residence and 
to doctors appointments. 
 
You asked the Plan to pre-approve the transportation services. You say that the transportation is medically 
necessary. The Plan denied your request. The Plan says the requested services do not meet the Medicare criteria 
for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office or transportation between residences 
are not covered destinations.  
 
The services you have asked the Plan to pre-approve are ambulance transport services to a doctors office and 
between residences. Therefore, we decided that the Plan does not have to pre-approve transportation services 
from residence to residence and to doctors appointments.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health visit and a clinic visit provided on March 
13, 2023, to April 27, 2023. 
 
You asked the Plan to pay for the mental health visit and a clinic visit. 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 mental health visit 
and a clinic visit provided on March 13, 2023, to April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 15, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating that this is 
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 an office visit provided 
on March 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve myocardial perfusion imaging. 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. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with cardiac imaging will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 myocardial perfusion imaging. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is insufficient 
documentation to support the medical necessity for the requested cardiac stress testing in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (78452).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay and IRF stay 
provided from March 3, 2023, to March 22, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay and an IRF stay. You say that you do 
not feel responsible to pay two hospital care copayments for the same diagnosis. 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 $350 
copayment per day for days 1 to 5 and $0 copayment for additional hospital days for inpatient hospital care.  
 
 You have been asked to pay $3,500 copayment for an inpatient hospital stay and IRF stay (a $350 copayment 
per day x 5 days = $1,750 per 5-day stay x 2 stays = $3,500). 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 inpatient hospital stay 
and IRF stay provided from March 3, 2023, to March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87186 billed for date of service November 
28, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says there is a more appropriate code that should be used. 
 
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 87186 is susceptibility studies, antimicrobial agent; 
microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-
antimicrobial, per plate. 
 
We find that CPT code 87186 is not supported in the medical record. The records do not show that this service 
was provided. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87186 billed 
for date of service November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a new patient office visit provided on 
October 22, 2022. 
 
You asked the Plan to waive the copayment for a new patient office visit. You say that you did not receive any 
treatment. 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 $65 
copayment for in and out-of-network urgently needed services. 
 
You have been asked to pay a $65 copayment for a new patient office visit. This item/service falls within the in 
and out-of-network urgently needed 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. However, the Plan is only holding you responsible for a $58.68 copayment 
which is less than the $65 copayment. Therefore, we decided that the Plan does not have to waive the 
copayment for a new patient office visit provided on October 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on April 21, 
2023. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you have been going to the same 
dental office for the past 5 years due to gum disease. You also say that you usually pay for care on the day of 
care and the dentist refunds you. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental benefits.  
 
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 out-of-network 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 out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodontal maintenance (D4910) provided on April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a metallic onlay (D2542) for tooth #5 provided by an out-of-
network provider on January 17, 2023. 
 
You asked the Plan to pay for the dental service. You say that the provider told you that they were in-network, 
and they accept your insurance. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental benefits. Also, the rendering 
provider is not your assigned dental facility. 
 
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 out-of-network provider and from a 
provider who is not your assigned dental 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 
out-of-network provider. Therefore, we decided that the Plan does not have to pay for a metallic onlay (D2542) 
for tooth #5 provided by an out-of-network provider on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve hearing aids. You say that the Plan should cover these hearing aids without 
further delay. The Plan denied your request. The Plan says they allow up to $1,050 per ear every 3 years, for a 
maximum of $2,100. The Plan also says that the total cost of the hearing aids is $4,300, which exceeds the 
allowance. 
 
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 up to 
$1,050 per hearing aid per year every three years.  
 
 
  We looked at the file and the Plan's rules. The Plan rules say that the Plan covers up to $1,050 per hearing aid 
per year every three years (maximum of $2,100). The record shows the benefit was exhausted with purchase. 
The record shows the remaining balance of $2,200 ($4,300 - $2,1000 = $2,200) is owed by the enrollee. Based 
on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, 
we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the injection provided on May 12, 2023. 
 
You asked the Plan to reduce the copayment for the injection. You say that the charges are excessive. 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 $235 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $235 copayment for the injection. 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. Therefore, we decided that the Plan does not have 
to reduce the copayment for the injection provided on May 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network diagnostic radiological 
scan provided on May 12, 2023. 
 
You asked the Plan to waive the copayment for an out-of-network diagnostic radiological scan. You say that 
you do not understand why you are getting this charge. 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 $50 
copayment for freestanding radiological facility. 
 
You have been asked to pay a $50 copayment for an out-of-network diagnostic radiological scan. This 
item/service falls within the freestanding radiological facility 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 out-of-network diagnostic radiological scan provided on May 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the adjunctive pre-diagnostic test (D0431), the biologic 
materials to aid in soft and osseous tissue regeneration (D4265), the guided tissue regeneration (D4266), the 
bone replacement graft (D7953), and the therapeutic drug (D9613). 
 
You asked the Plan to pre-approve the dental services. You say that the dental services should be covered 
because they are medically necessary, and you are in pain. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because the adjunctive pre-diagnostic test, the biologic 
materials to aid in soft and osseous tissue regeneration, the guided tissue regeneration, the bone replacement 
graft, and the therapeutic drug 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 pre-approve the 
adjunctive pre-diagnostic test (D0431), the biologic materials to aid in soft and osseous tissue regeneration 
(D4265), the guided tissue regeneration (D4266), the bone replacement graft (D7953), and the therapeutic drug 
(D9613).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trimming of skin lesions provided on May 12, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the trimming of skin lesions. You say that you are appealing the denial with 
supporting documentation. 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 the trimming of skin lesions provided on May 12, 
2023, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network computed tomography (CT) 
scan provided on April 28, 2023. 
 
You asked the Plan to waive the copayment for an in-network computed tomography (CT) scan. You say that 
you were never told you would have this copayment. You cannot afford it, and if you had known you would be 
charged you would have gone elsewhere. 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 an in-network computed tomography (CT) 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 an in-network computed tomography (CT) scan provided on 
April 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a benralizumab injection provided on May 
15, 2023. 
 
You asked the Plan to waive the coinsurance for a benralizumab injection. You say that you were told that 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a benralizumab injection. 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. The total you owe is $1,020.90 ($5,104.50 allowed amount x 20% = $1,020.90). 
Therefore, we decided that the Plan does not have to waive the coinsurance for a benralizumab injection 
provided on May 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty. 
 
You asked the Plan to pre-approve a total knee arthroplasty. You say that the enrollee needs this surgery. The 
Plan denied your request. The Plan says the enrollee has not met the medical criteria for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 a total knee arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. No compelling rationale is presented, 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested right total knee arthroplasty is not medically reasonable or 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 a total knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on November 25, 2022, billed with 5 
units of code 83520 and 1 unit of code 87798. 
 
You asked the Plan to pay for the lab testing as billed. You say that this claim should be paid as billed.  The 
Plan denied your request. The Plan says the two codes which remain denied are not supported. 
 
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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. 
 
We find that these two codes are not supported in the medical record. Specifically, these are not otherwise 
specified codes, and no information has been provided to indicate the analytes tested with the codes. Based on 
this information, we decided that Medicare rules for coverage of the lab testing as billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab testing provided on November 25, 2022, 
billed with 5 units of code 83520 and 1 unit of code 87798.