Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the left hearing aid (V5256) provided on 
September 1, 2022. 
 
You asked the Plan to reduce the copayment. You say that you were told that the hearing aid in this case would 
only be $350. 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 $500 
copayment per hearing aid, limited to two aids per calendar year.  
 
You have been asked to pay a $500 copayment for the hearing aid provided in this case. 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 left hearing aid (V5256) provided on 
September 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81456) provided on June 21, 2023. 
 
You asked the Plan to pay for the lab 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 CMS policy prohibits separate payment for 
duplicate testing or testing for the same analyte by more than one methodology. 
 
We looked at the file and Medicare rules. The same test was previously paid on claim 820231810399512. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81456) provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve image guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that the services are necessary. The Plan denied your 
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 IGRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found IGRT would be within an accepted standard of care when using 3D conformal techniques for 
aggressive palliation. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
image guided radiation therapy (IGRT).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on July 18, 
2023, to July 26, 2023. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that this should be covered 
100%. 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 $325 
copayment for inpatient hospital services. 
 
You have been asked to pay a $325 copayment for an acute inpatient stay. This item/service falls within the inpatient 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. You have been asked to pay a total of $1,625 for the inpatient hospital stay ($325 
copayment x 5 days = $1,625). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on July 18, 
2023, to July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for dialysis services provided on August 02, 
2023, to August 30, 2023. 
 
You asked the Plan to reduce the coinsurance for dialysis services. You say that you have met your yearly total 
out of pocket expense. 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 services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for dialysis services. This item/service falls within the services to 
treat kidney disease 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 coinsurance for dialysis services 
provided on August 02, 2023, to August 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluations (D0140) and the recement or re-
bond inlay (D2910) for tooth #10 provided on August 11, 2023, and September 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are asking the Plan to reconsider payment 
for the dental services. The Plan denied your request. The Plan says your benefit for the requested items or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a limited oral evaluation (D0140) on February 11, 2023, and May 2, 2023; therefore, 
your benefit for the limited oral evaluations (D0140) was exhausted on the date of service of May 2, 2023. The 
record also shows that the Plan paid for a recement or re-bond inlay (D2910) for tooth #10 on May 2, 2023; 
therefore, your benefit for the recement or re-bond inlay (D2910) for tooth #10 was exhausted on the date of 
service of May 2, 2023. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluations (D0140) and the recement or re-bond inlay (D2910) for tooth #10 provided on August 11, 2023, 
and September 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit and follow up provided from 
August 24, 2023, to August 29, 2023. 
 
You asked the Plan to waive the deductible for an office visit and follow up. You say that you went to this 
office multiple times and had tests done, and no one told you they were out-of-network until you got the bill. 
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. Your 
contract with the Plan says that there is a $1000 deductible which applies to physician/practitioner services, 
including doctors office visits. Youve been asked to pay $373.26 towards this $1000 deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1000 deductible which applies to physician/practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time an 
office visit and follow up was received on August 24, 2023, to August 29, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an office visit and follow up provided from August 24, 2023, to 
August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing-four or more teeth 
per quadrant (D4341 x 2) rendered by the out-of-network (OON) provider on November 2, 2023.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization.  
 
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 Plan had network providers available who were capable of providing the services at issue in this appeal. 
(Please note, items and services received in-network are still subject to any other Medicare coverage rules that 
apply.) 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 periodontal scaling 
and root planing-four or more teeth per quadrant (D4341 x 2) rendered by the out-of-network (OON) provider 
on November 2, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
25, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not know this 
was an actual ambulance 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 $230 
copayment for in-network ambulance services. 
 
You have been asked to pay a $230 copayment for the ambulance services. This item/service falls within the 
in-network 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 services provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus and Diphtheria toxoids (Td) vaccine (90714) and 
immunization administration (90472) provided September 14, 2023. 
 
You asked the Plan to pay for the immunization services. You say that you received a bill of $98.00 and 
usually these are covered. The Plan denied your request. The Plan says the services received are not covered 
under Part B medications or your medical benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pay for the Tetanus and Diphtheria toxoids (Td) vaccine (90714) and immunization 
administration (90472) provided September 14, 2023.  
 Benefits for the immunization services may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
August 22, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service February 1, 2022.   
 
Specifically, the Plans contract states that one comprehensive oral evaluation is covered every three calendar 
years. You previously received this service on February 1, 2022, less than three years prior, which was paid for 
by the Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve a heart PET scan. 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 cardiac radionuclide imaging is covered 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 a heart PET scan. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation that the 
electrocardiogram (ECG) shows an uninterpretable pattern. There is no evidence provided that would support 
the need for radionuclide stress testing at this time. In summary, there is insufficient documentation to support 
the medical necessity for the requested cardiac stress testing in this enrollee's 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 a heart PET scan have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a heart positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic eye examination (92004) provided on August 
09, 2023. 
 
You asked the Plan to pay for a diagnostic eye examination (92004). You say that there is no authorization 
located in the chart. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 diagnostic eye examination (92004) provided on August 09, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve percutaneous transluminal angioplasty (PTA) and carotid stenting 
(37215). 
 
You asked the Plan to pre-approve PTA and carotid stenting. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that PTA is covered when used under certain conditions 
 
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 PTA and carotid stenting. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the documentation meets 
coverage criteria and supports the medical necessity of the procedure in question. There is documentation that, 
on review by the vascular surgeon, the degree of carotid stenosis on the left is >80%. She has a history of 
congestive heart failure (high risk) and already had met criteria for transcarotid artery revascularization 
(TCAR) as she is status post TCAR on the right. While the carotid ultrasound did not demonstrate the high-
grade stenosis, the result is qualified by documentation that the area was difficult to image with ultrasound. 
Based on the above information, there is satisfactory documentation to support the plan for left TCAR as 
reasonable and medically necessary, and coverage criteria have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PTA and carotid stenting have been met. Therefore, we decided that the Plan 
has to pre-approve percutaneous transluminal angioplasty (PTA) and carotid stenting (37215).  
 
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 pay for procedure code 99214 provided on October 30, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 99214 provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 
procedure code 99214 provided on October 30, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on September 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 30, 2023 and 
June 12, 2023. Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on 
September 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308 provided on September 18, 2023, to 
September 19, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 99308. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide OON care. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 
procedure code 99308 provided on September 18, 2023, to September 19, 2023, by an out-of-network (OON) 
provider.