Persius/hicric huggingface dataset:
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 
November 23, 2022. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that this will cause a 
financial hardship, you want to see if anything can be lowered or waived. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 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 November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on December 16, 2022. 
 
You asked the Plan to pay for a home visit. You say that we depend on the facility staff to verify eligibility and 
to obtain authorization. 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 home visit provided on 
December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality test (D0460) provided on December 30, 
2022. Additionally, the Plan does not have to waive the deductible applied to the intraoral-periapical first 
radiographic image (D0220) and the limited oral evaluation (D0140) provided on December 30, 2022. 
 
You asked the Plan to pay for the pulp vitality test. Additionally, you asked the Plan to waive the deductible 
applied to the intraoral-periapical first radiographic image and the limited oral evaluation provided. You say 
that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The 
Plan says a pulp vitality test is not a covered benefit. Additionally, the Plan says the deductible has been 
applied correctly to the services provided.  
 
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 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 $100 
annual deductible for Class 2 Basic Services and Class 3 Major Services before cost sharing. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the pulp vitality test provided is not 
among those covered under this benefit. Additionally, you have been asked to pay a $90.86 deductible for the 
intraoral-periapical first radiographic image and the limited oral evaluation provided. The Plan contract states 
that there is a $100 annual deductible applied for Class 2 and Class 3 dental services provided. The record 
shows that you have not previously met the yearly deductible. 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, the Plan does not have to pay for the pulp vitality test (D0460) 
provided on December 30, 2022. Additionally, the Plan does not have to waive the deductible applied to the 
intraoral-periapical first radiographic image (D0220) and the limited oral evaluation (D0140) provided on 
December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit provided on December 06, 
2022. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that you are disputing the share cost. 
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 office visit. This item/service falls within the Medicare 
Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an office 
visit provided on December 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110) provided on January 25, 2023, 
by an OON provider. 
 
You asked the Plan to pay for the dental services. You say that the enrollee has to see the OON provider due to 
special needs condition. 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 prophylaxis - adult (D1110) provided on January 25, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service September 
11, 2022. You asked the Plan to pay for the billed services. You say that the medical records support the services.  The 
Plan denied your request. The Plan says the services are included in the global surgery period of a major 
surgery.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99291 was billed within the 90-day time frame of a major global surgical procedure. 
The code at issue was not billed with a modifier to indicate the service was unrelated to the surgical procedure. 
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 99291 billed for date of 
service September 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy from November 30, 2022. 
 
You asked the Plan to pay for massage therapy. You say that this should be covered. The Plan denied your 
request. The Plan says massage therapy is not a covered benefit under the wellness allowance. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The Plans rules for coverage of gym benefits have not been met because massage therapy is not covered under 
the wellness allowance. Therefore, we decided that the Plan does not have to pay for massage therapy from 
November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for dates of service March 1, 
2022, to March 5, 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 the billed codes cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that CPT code 99232 was billed for dates March 1, 2, 3, and 5, 2022. We find that CPT code 
99232 is not supported in the medical record. Specifically, the records provided do not include evaluation and 
management services for these dates.  
 
CPT code 99232-25 was billed for March 4, 2022. We find that this code is included in the minor procedure 
code 43239 billed on the same date of service. There are insufficient medical records to show that an evaluation 
and management service was a significant and separately identifiable service. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 99232 billed for dates of service March 1, 2022, to March 5, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 28, 2022, 
through September 30, 2022. 
 
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 that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on September 28, 2022 with chest pain.  
He was evaluated and noted to have an increased troponin and an electrocardiogram with a Mobitz II block.  
He was evaluated by Cardiology and was admitted. He underwent a cardiac catheterization which revealed 
nonobstructive disease. He was also evaluated by Gastroenterology and underwent an upper endoscopy. His 
condition stabilized and improved and he was discharged home when considered medically stable on 
September 30, 2022. The review has determined that the record showed that at the time of the inpatient 
admission the admitting physician reasonably expected that the enrollees necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from September 28, 2022, through September 30, 2022.  
 
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 reduce the copayment for an in-network specilist visit provided on 
January 11, 2023. 
 
You asked the Plan to reduce the copayment for an in-network specilist visit. You say that you want this 
lovered from a $40 copayment to a $10 copayment, since the provider is a primary care provider and not a 
specialist. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for an in-network specilist visit. This item/service falls within the 
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. This was an emergency specialist, therefore, the 
$40 copayment is upheld. Therefore, we decided that the Plan does not have to reduce the copayment for an in-
network specilist visit provided on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341) provided on December 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that your dentist assured you that they did not 
exceed the allowed coverage during the course of the treatment for the year 2022. You also say that you intend 
to contact your dentist to obtain more information which you will then forward. The Plan denied your request. 
The Plan says your benefit for the requested service $1,000 dollar limit was met. 
 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 services November 4, 2022, and  
December 8, 2022. The total amount of the claim on November 4, 2022 was $410 which was fully paid, and 
date of service December 8, 2022, $570 was also fully paid ($410 + $570 = $980). You had used all but $20 on 
these claims and this amount was used leaving you liable for the balance of $430. Therefore, we decided that 
the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per quadrant 
(D4341) provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and cone beam computed 
tomography (CT) capture and interpretation (D0367) provided on January 24, 2023. 
 You asked the Plan to pay for the problem focused limited oral evaluation, intraoral periapical x-rays, and cone 
beam CT capture and interpretation. You say that you made sure what this visit would cost you before you saw 
the dentist and were told $41, which you paid that day. You also say that you were not advised that you would 
be charged for x-rays. The Plan denied your request. The Plan says these services are not covered expenses 
under your dental plan. The Plan also says when you contacted the Plan prior to this date of service, you were 
advised that the Plan is code specific. 
 
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 the 
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), additional intraoral 
periapical x-ray (D0230), and cone beam computed tomography (CT) capture and interpretation (D0367) 
provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a podiatry visit provided on August 15, 2022. 
 
You asked the Plan to pay for a podiatry visit. You say that this was 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 podiatry visit provided 
on August 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hand procedure provided on October 04, 2022. 
 
You asked the Plan to pay for a hand procedure. You say that we depend on the clinic to get prior 
authorizations or any other paperwork prior to a procedure. 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 hand procedure 
provided on October 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for localized delivery of antimicrobial agents via a controlled 
release (D4381) provided on February 1, 2023. 
 
You asked the Plan to pay for localized delivery of antimicrobial agents via a controlled release. You say that 
this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 
localized delivery of antimicrobial agents via a controlled release (D4381) provided on February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft  retained natural tooth  first 
site in quadrant (D4263). 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services due to mouth 
pain. The Plan denied your request. The Plan says this service is not covered under your 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. Bone replacement graft  
retained natural tooth  first site in quadrant (D4263) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4263 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft  retained natural tooth  first site in quadrant (D4263).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the step therapy requirements 
have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically necessary. Our physician reviewer found that the record indicates that the enrollee 
has iron deficiency anemia. Although the requested medication is a new start there is no indication that the 
enrollee has tried and failed the Plan's preferred step one alternative. There is no indication that the enrollee has 
a contradiction to or would have an adverse effect from the Plan's preferred step one alternative. Therefore, the 
elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.