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

 
We decided that the Plan does not have to pay for air ambulance services provided on March 26, 2023. 
 
You asked the Plan to pay for the air ambulance services. You say that your mother had a brain aneurysm and 
was non-responsive. You say that you panicked because you were away in a foreign country, and you feared 
for her life. You say that the doctor in Mexico suggested getting an air ambulance to get her back to the United 
States. You say that you trusted that the Plan would aid in the assistance needed.  The Plan denied your request. 
The Plan says the air ambulance services were not authorized and the appellant self-referred. 
 
The Plan follows Medicare rules. Medicare rules say that ambulance transport is covered to the nearest 
appropriate facility equipped to treat the patient. Medicare rules say that, generally, items and services provided 
outside of the United States are not covered. However, the Plan offers worldwide emergency care coverage that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
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 air ambulance services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found that the documentation 
provided did not support that the transferring hospital did not have adequate facilities to provide the medical 
services needed by the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Though the Plan offers a worldwide 
emergency care benefit in excess of Medicare coverage, the services in dispute do not meet their guidelines for 
coverage under this benefit. Specifically, the services in dispute would not have been covered if they were 
received from a network provider. Based on this information, we decided that Medicare rules for coverage of the air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air 
ambulance services provided on March 26, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the psychotherapy visit provided on October 3, 2022. 
 
You asked the Plan to reimburse for the psychotherapy visit. You say that you need to be reimbursed for the 
amount you paid for your visit. 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 for mental health 
services enrollees must pay a $65 copayment for partial hospitalization. 
 
You have been asked to pay a $65 copayment for the psychotherapy visit. This item/service falls within the 
mental health 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 reimburse for the psychotherapy visit 
provided on October 3, 2022. 
 
Please note that neither you nor the Plan are responsible for paying the balance bill. Please contact the 
provider about a refund for any amount you paid above the Medicare allowable amount for the urgent care 
visits. If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the 
Plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental implants provided on May 23, 2022. 
 
You asked the Plan to pay for dental implants. You say that this dental work should be covered. The Plan 
denied your request. The Plan says the denied dental services are not covered 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. 
 
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 dental 
implants provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on 
June 7, 2023. 
 
You asked the Plan to pay for D1999. You say that you needed these services because you were at risk of 
further complications. The Plan denied your request. The Plan says the rendered dental service is not a covered 
benefit. 
 
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 
unspecified preventive procedure (D1999) provided on June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), surgical extractions 
(D7120), a bone replacement graft (D7953), and a guided tissue regeneration (D7957) provided on June 20, 
2023. 
 
You asked the Plan to pay for D0140, D7120, D7953, and D7957. You say that you needed all of this dental 
work. The Plan denied your request. The Plan says the rendered dental services are not covered 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. 
 
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 a limited oral evaluation (D0140), surgical extractions (D7120), a bone replacement graft (D7953), and a guided tissue 
regeneration (D7957) provided on June 20, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the home infusion therapy (S9328) provided May 21, 2023, through 
June 17, 2023. 
 
You asked the Plan to pay for the services. You say that please refer to the authorization number, granting a 
waiver and approving codes S9328, 99601, 99602, 62368 and 62329 for this provider. The Plan denied your 
request. The Plan says that this code is not used for Medicare purposes. 
 
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 Plan failed to provide the authorization to verify what services were 
approved by the Plan; therefore, we could not verify if S9328 was approved. Therefore, we decided that the 
Plan has to pay for the home infusion therapy (S9328) provided May 21, 2023, through June 17, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that this treatment is medically necessary. The Plan denied 
your request. The Plan says that there is not enough evidence that this type of radiation therapy guidance is 
needed or effective for the enrollee's skin cancer. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found using ultrasound on a daily basis is not unreasonable to offer but is not necessary. Using daily 
IGRT for a technology for which the need has not been established is not necessary. This would not be 
furnished in accordance with accepted standards of medical practice. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an out-of-network provider. The Plan 
denied your request. The Plan says you must receive your care from a network provider. An exception to 
the rule is for emergency or urgently needed services that you cannot get from a network provider. Based on 
the documentation we received from your provider, there is no clinical indication why you need to receive 
services with this out of network provider, therefore the request is denied.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on June 30, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are requesting reconsideration for 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 home visit provided 
on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 4, 2023, billed with 
procedure codes 00944 and 99100. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that N81.11 has an Excludes1 note in relation to N81.2. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does 
not have to pay for practitioner services provided on April 4, 2023, billed with procedure codes 00944 and 
99100.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography scan provided on 
July 21, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography scan. You say that you were unaware 
of the cost for this facility. 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for a computed 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. However, since the allowed amount is less than the 
standard copayment, you only owe $115.69. Therefore, we decided that the Plan does not have to waive the 
copayment for a computed tomography scan provided on July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve block and a femoral nerve block 
(64447 and 64450). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says a peripheral nerve block and a femoral nerve block are considered 
investigational. 
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this would be considered experimental therapy. Therefore, the request is deemed 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a peripheral nerve block and a femoral nerve block (64447 and 64450).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost sharing for the office visit provided by an out-of-network 
provider on May 23, 2023. 
 
You asked the Plan to waive the cost sharing for the office visit. You say that you were not informed that this 
provider was not in-network. The Plan denied your request. The Plan says that this cost sharing was charged 
correctly. 
 
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 Plan did not provide the correct 2023 Evidence of Coverage (EOC). 
Therefore, we decided that the Plan has to waive the cost sharing for the office visit provided by an out-of-
network provider on May 23, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
06, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were told that you 
would not have a 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 $25 
copayment for outpatient hospital services. 
 
You have been asked to pay a $25 copayment for a specialist office visit. This item/service falls within the 
outpatient hospital 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 a specialist 
office visit provided on June 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on March 28, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim partial maxillary denture (D5820) provided on 
March 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you should not owe anything. The Plan denied 
your request. The Plan says your annual dental allowance amount of $2,000 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 annual dental allowance amount was exhausted on date of service March 7, 2023. Therefore, we 
decided that the Plan does not have to pay for an interim partial maxillary denture (D5820) provided on March 
7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0270) provided on May 6, 2023. 
 
You asked the Plan to pay for D0270. You say that you believe this should be covered. The Plan denied your 
request. The Plan says this dental work has been correctly denied. 
 
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 Plan covers D0270 when 
the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of D0270 have not been met. The same provider preformed both D0270. Therefore, we decided that 
the Plan does not have to pay for bitewings (D0270) provided on May 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bupivacaine (J3490) provided on July 7, 2023. 
 
You asked the Plan to pay for Bupivacaine. You say that the treatment at issue was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says payment for Bupivacaine is included in the global 
surgery package of procedure code 64493. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (64493) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for Bupivacaine (J3490) provided on July 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a home ventilator provided on January 03, 
2023, to February 03, 2023. 
 
You asked the Plan to waive the coinsurance for a home ventilator. You say that you were not informed of the 
cost share. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for a home ventilator. This item/service falls within the durable 
medical equipment 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 a home ventilator provided on January 03, 2023, to February 03, 2023.