Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation and 
management of an established patient (99335) provided on December 14, 2022, by an out-of-network (OON) 
provider.  
 You asked the Plan to pay for domiciliary or rest home visit for the evaluation and management of an 
established patient. You say that the providers rely on facility staff to verify eligibility and obtain authorization. 
The Plan denied your request. The Plan says the services were not urgent or emergent and the services could 
have been rendered by a participating provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation 
and management of an established patient (99335) provided on December 14, 2022, by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on January 30, 
2023. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that these charges are a duplicate. 
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 $200 
copayment for outpatient hospital services. 
 
You have been asked to pay a $200 copayment for the arthrocentesis. 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. The record shows this is not a duplicate charge. Therefore, we decided that the Plan does 
not have to waive the copayment for the arthrocentesis provided on January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nail debridement provided on January 
26, 2023. 
 
You asked the Plan to waive the copayment for the nail debridement. You say that you never had to pay to get 
your nails cut before. 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 podiatry services. 
 
You have been asked to pay a $40 copayment for the nail debridement. This item/service falls within the 
podiatry 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 nail debridement 
provided on January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a continuous glucose monitor (CGM) have not been met.  Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
December 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that this would not be 
covered. 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 March 17, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear purchased on January 5, 2023, from an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eyewear purchased. You say that you were not made aware that you do not 
have OON benefits for vision, and that the treating provider is non-participating with the Plan. You also say 
that you want your money back. The Plan denied your request. The Plan says OON vision care is not covered 
by the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the eyewear purchased on January 5, 2023, from 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0140, D0460 and D0380) on December 
8, 2022. 
 
You asked the Plan to pay for the dental services (D0140, D0460 and D0380). You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the 
requested service (D0140) 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 November 2, 2022 (D0140). The dental services (D0460 and D0380) are not covered. Therefore, we decided that the Plan does not 
have to pay for the dental services (D0140, D0460 and D0380) on December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on September 09, 2022, to 
November 21, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that this was medically necessary and should be 
covered. The patient is in a facility and cannot choose their own provider. 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 nursing facility visit 
provided on September 09, 2022, to November 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation and 
management of an established patient (99335) provided on December 27, 2022, by an out-of-network (OON) 
provider.  
 You asked the Plan to pay for domiciliary or rest home visit for the evaluation and management of an 
established patient. You say that the facility is responsible to obtain prior authorization. The Plan denied your 
request. The Plan says the services were not urgent or emergent and the services could have been rendered by a 
participating provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation 
and management of an established patient (99335) provided on December 27, 2022, by an out-of-network 
(OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ambulance transportation provided on 
February 12, 2023. 
 
You asked the Plan to reduce the copayment for the ambulance transportation. You say that you say the 
transportation was medically necessary. 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 $260 
copayment for ambulance services. 
 
You have been asked to pay a $260 copayment for the ambulance transportation. 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. However, since the allowed amount is less than the standard copayment, you only owe 
$254.17. Therefore, we decided that the Plan does not have to reduce the copayment for the ambulance 
transportation provided on February 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on December 21, 2022. 
 
You asked the Plan to pay for mental health services. 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 mental health services 
provided on December 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the arthrocentesis provided on January 26, 
2023. 
 
You asked the Plan to reduce the copayment for the arthrocentesis. You say that the injection cost is too high. 
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 $290 
copayment for in-network outpatient surgery provided at hospital outpatient facilities. 
 
You have been asked to pay a $290 copayment for the arthrocentesis. This item/service falls within the in-
network outpatient surgery provided at hospital outpatient facilities benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the copayment for the arthrocentesis provided on January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided from May 4, 2020, to November 
10, 2022. 
 
You asked the Plan to pay for diabetic supplies. You say that you do you not believe the enrollee owes the 
amount due. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Diabetes self-management training, diabetic services, and supplies.  
 
  The enrollee has been asked to pay 20% coinsurance for diabetic supplies. This item/service falls within the 
diabetes self-management training, diabetic services, and supplies benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to pay for diabetic supplies provided from May 4, 2020, to November 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary for you. If you 
are provided a lower level of care, your return home will be delayed significantly. The Plan denied your 
request. The Plan says your needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  You were admitted for 
orbital wall fracture, small intracranial bleed and chronic C 1 fracture after a fall and were discharged home on 
May 10, 2023. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for IV infusion therapy provided on January 
16, 2023. 
 
You asked the Plan to waive the coinsurance for IV infusion therapy. You say that you have not had to pay a 
copayment previously, so you do not understand why you are being billed one now. 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 IV infusion therapy. 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 $636.16 ($3,180.79 allowed amount x 20% = $636.16). 
Therefore, we decided that the Plan does not have to waive the coinsurance for IV infusion therapy provided on 
January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4267) for tooth #8 provided 
on March 6, 2023. 
 
You asked the Plan to pay for the dental service. You say that your dentist said the dental procedures was 
necessary for an implant and you are appealing the denied bone graft. The Plan denied your request. The Plan 
says the denial of payment for this service is correct because the guided tissue regeneration is not covered by 
the Plan. Also, the bone graft was paid for with the proper cost shared applied. 
 
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 guided tissue 
regeneration is not among those covered under this benefit. Also, the record shows that the bone replacement 
graft (D7953) was not denied and a total allowed amount for the bone replacement graft was $450 with a 
coinsurance amount of $255 ($450 allowed x 50% coinsurance). Therefore, we decided that the Plan does not 
have to pay for the guided tissue regeneration (D4267) for tooth #8 provided on March 6, 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), each additional site in quadrant (D4264), biologic materials to aid in soft and osseous 
tissue regeneration, per site (D4265), and osseous surgery (including elevation of a full thickness flap and 
closure)  one to three contiguous teeth or tooth bounded spaces per quadrant (D4261). 
 
You asked the Plan to pre-approve the dental services represented by codes D4263, D4264, D4265 and D4261. 
You say that this should be covered as it is a follow-up to your periodontal scaling and root planning (D4341) 
you had in January 2023. The Plan denied your request. The Plan says procedure codes D4261, D4263, D4265, 
and D4264, are not listed as covered benefits under the enrollees dental 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 pre-approve 
bone replacement graft  retained natural tooth  first site in quadrant (D4263), each additional site in quadrant 
(D4264), biologic materials to aid in soft and osseous tissue regeneration, per site (D4265), and osseous 
surgery (including elevation of a full thickness flap and closure)  one to three contiguous teeth or tooth 
bounded spaces per quadrant (D4261).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial denture (D5214) provided on August 22, 
2022. 
 
You asked the Plan to pay for mandibular partial denture. 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 
mandibular partial denture (D5214) provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided on 
February 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 June 20, 2022. Therefore, 
we decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided on 
February 9, 2023.