Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy provided on January 18, 2023. 
 
You asked the Plan to pay for the psychotherapy. 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 psychotherapy 
provided on January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis procedures, and related services provided on May 
02, 2023, to May 30, 2023. 
 
You asked the Plan to pay for dialysis procedures, and related services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for dialysis procedures, and 
related services provided on May 02, 2023, to May 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional amount for the 
maxillectomy/palatectomy prostheses-obturator provided on September 1, 2022. 
 
You asked the Plan to reimburse you an additional amount for the maxillectomy/palatectomy prostheses-
obturator. You say that the procedure code provided is only covering the prosthetic mold portion of the 
procedure and does not take into account that there was also the insertion of the prosthetic device within your 
palate. The Plan denied your request. The Plan says the Plan called the provider and the provider said that the 
code billed is the only code needed. The claim processed with the correct Medicare allowable amount. 
 
The Plan contract says if you receive the covered services from an out-of-network provider who participates 
with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating 
providers. 
 
We looked at the file and the Plans rules. The file shows that the provider used the correct code for the 
services that were rendered. The Plan has reimbursed you the correct Medicare allowable amount. Therefore, 
we decided that the Plan does not have to reimburse you an additional amount for the 
maxillectomy/palatectomy prostheses-obturator provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910), and topical fluoride 
varnish (D1206) provided on May 9, 2022. 
 
You asked the Plan to pay for D4910 and D1206. You say that you would like the plan to pay for this. 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 
periodontal maintenance (D4910), and topical fluoride varnish (D1206) provided on May 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
October 23, 2022. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that this is too much, 
please lower this amount. 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 $440 
copayment for ambulance services. 
 
You have been asked to pay a $440 copayment for an in-network ambulance ride. This item/service falls within 
the ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an in-
network ambulance ride provided on October 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would not get the care he 
needs at a skilled nursing facility. You say that the enrollee still needs daily labs and monitoring by a physician 
and a wound that would need to be monitored.  The Plan denied your request. The Plan says the LTACH 
services are not medically necessary, and the enrollee's needs can be met at a lower level of care such as a 
skilled nursing facility.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a past medical history of diabetes (Type II), peripheral arterial disease, coronary artery disease, chronic obstructive pulmonary disease, hypertension, and anemia. The 
enrollee underwent a femoral-popliteal artery bypass graft that failed, and he required a right below-knee 
amputation. The enrollee was readmitted for ischemia of his amputation site wound requiring debridement and 
washout and then conversion to above-knee amputation. He was also found to have an L4-5 osteomyelitis/ 
discitis with a treatment recommendation for medical management. The enrollee has a groin wound vacuum in 
place and the amputation site is clean, dry, and intact. This means that the enrollee's needs can be met at a 
lower level of care. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve WEGOVY (C9399). 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve WEGOVY (C9399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950), gingivectomy/gingivoplasty 
(D4212), intraoral imaging (D0220), a crown (D2740), endodontic therapy (D3330), and anesthesia (D9230), 
provided on May 9, 2023, to May 23, 2023. 
 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the denied services have 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D0220 was exhausted on date of service February 9, 2023. The records show that your 
annual dental allowance amount of $2,500 was exhausted on May 23, 2023. Therefore, we decided that the 
Plan does not have to pay for a core build-up (D2950), gingivectomy/gingivoplasty (D4212), intraoral imaging 
(D0220), a crown (D2740), endodontic therapy (D3330), and anesthesia (D9230), provided on May 9, 2023, to 
May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on June 01, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and needs to be 
covered. 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 laboratory testing 
provided on June 01, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on June 20, 2023. 
 
You asked the Plan to pay for an x-ray. You say that you say that the patient is confined to a nursing home and 
is unable to receive service elsewhere. 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 x-ray provided on 
June 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network injectable immune globulin 
treatments provided on April 05, 2023, to April 26, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network injectable immune globulin treatments. You say 
that you had covid and could not take the infusions. No one told you what to do with them. 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 an in-network injectable immune globulin treatments. 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 $252.48 ($1262.40 x 20% = 
$252.48). The total you owe is $1009.92 ($252.48 allowed amount x 4 visits = $1009.92). Therefore, we 
decided that the Plan does not have to waive the coinsurance for an in-network injectable immune globulin 
treatments provided on April 05, 2023, to April 26, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic eye scan provided on April 10, 
2023. 
 
You asked the Plan to waive the copayment for diagnostic eye scan. You say that you say that you should be 
responsible for a reduced copayment because it was not an x-ray. 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 $30 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
You have been asked to pay a $30 copayment for diagnostic eye 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 diagnostic eye scan provided on April 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the thorax. 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that the CT scan was ordered because the 
enrollee was suffering from chest pain. The Plan denied your request. The Plan says a CT scan of the thorax is 
not medically necessary. 
 
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 a CT scan of the thorax. Our reviewer 
says that a CT scan of the thorax is not medically necessary. Our physician reviewer found that the standard of 
care testing for the enrollee's conditions should include a restart of proton pump inhibitor therapy, upper 
endoscopy, and abdominal imaging. Furthermore, the medical appropriateness, and necessity of the thoracic 
CT scan at this junction in the enrollee's care is not supported by the available records. 
 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 CT scan of the thorax have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the thorax.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 24, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the OIVIT services should be paid as billed 
because they are supported in the medical record. The Plan denied your request. The Plan says the OIVIT 
services are denied because they are not supported in the medical record. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on April 29, 2022. 
 
You asked the Plan to pay for a chest x-ray. You say that this is medically necessary, and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a chest x-ray provided 
on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99203), infrared therapy (97026), manual 
therapy (97140), supplies and materials (99070), electromagnetic therapy (G0295), mechanical traction therapy 
(97012), neuromuscular re-education (97112), chiropractic manipulative treatment (98941) and unlisted 
procedure code (99999) provided from February 28, 2023, to March 16, 2023. 
 
You asked the Plan to pay for an office visit (99203), infrared therapy (97026), manual therapy (97140), 
supplies and materials (99070), electromagnetic therapy (G0295), mechanical traction therapy (97012), 
neuromuscular re-education (97112), chiropractic manipulative treatment (98941) and unlisted procedure code 
(99999). You say that none of your claims have been accurately addressed. The Plan denied your request. The 
Plan says the copayment for the chiropractic manipulative treatment (98941) was charged correctly. The Plan 
also says the remaining services are denied as they are not covered services when provided by a chiropractor. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The rules also say that the only chiropractic service Medicare 
covers is manual manipulation of the spine to correct a subluxation.  
 
You have been asked to pay a $30 copayment for chiropractic manipulative treatment. This item/service falls 
within the chiropractic services benefit category. The remaining services are denied as they are non-covered 
services when provided by a chiropractor. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for an office 
visit (99203), infrared therapy (97026), manual therapy (97140), supplies and materials (99070), 
electromagnetic therapy (G0295), mechanical traction therapy (97012), neuromuscular re-education (97112), 
chiropractic manipulative treatment (98941) and unlisted procedure code (99999) provided from February 28, 
2023, to March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on February 13, 2023. 
 
You asked the Plan to pay for physicians services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physicians services 
provided on February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for areola tattooing provided on June 7, 2023. 
 
You asked the Plan to reimburse you for areola tattooing. You say that the areola tattooing is medically 
necessary for your health and wellbeing and a component of breast reconstruction. The Plan denied your 
request. The Plan says the requested provider is not contracted with the Plan and not a Medicare provider. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The file shows that this tattoo provider does not participate in the 
Medicare program. Therefore, we decided that the Plan does not have to reimburse you for areola tattooing 
provided on June 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit and the application of a 
compression system provided on June 13, 2023, to June 19, 2023. 
 
You asked the Plan to waive the coinsurance for an office visit and the application of a compression system. 
You say that these services were fully covered in the past. 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 out-of-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 20% coinsurance for an office visit and the application of a compression system. This item/service falls within the out-of-network physician/practitioner services, including doctors office visits 
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 an office visit and the 
application of a compression system provided on June 13, 2023, to June 19, 2023.