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

 
We decided that the Plan does not have to waive the coinsurance for CT ABD & PELV 
W/CONTRASTcomputed tomography (CT) of the abdomen and pelvis provided on February 09, 2023. 
 
You asked the Plan to waive the coinsurance for CT ABD & PELV W/CONTRASTcomputed tomography 
(CT) of the abdomen and pelvis. You say that you should not be responsible to pay this. 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 CT scan. 
 
You have been asked to pay 20% coinsurance for CT ABD & PELV W/CONTRASTcomputed tomography 
(CT) of the abdomen and pelvis. This item/service falls within the CT scan 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. Your contract with the Plan states your 
cost share for x-ray, radiation therapy, diagnostic radiology services, and other outpatient diagnostic test 
services in a single day will not exceed $75. Therefore, we decided that the Plan does not have to waive the 
coinsurance for CT ABD & PELV W/CONTRASTcomputed tomography (CT) of the abdomen and pelvis 
provided on February 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391) for tooth #11 provided on 
April 14, 2023. 
 
You asked the Plan to pay for the dental service. You say that the procedure was a preventive procedure, and it 
was medically necessary for you to get it done. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the resin-based composite is not covered by the 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite (D2391) for tooth #11 provided on April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of hyperplastic tissue (D7970) and the 
removable appliance therapy (D8210) provided by on November 1, 2022, and December 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not have any knowledge of when the 
previous plan would end and you would like the dental services backdated. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because the excision of hyperplastic tissue and the 
removable appliance therapy are not covered by the 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. 
 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 
excision of hyperplastic tissue (D7970) and the removable appliance therapy (D8210) provided by on 
November 1, 2022, and December 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each emergency room (ER) visit provided 
on June 06, 2023, to June 07, 2023. 
 
You asked the Plan to waive the copayment for each emergency room (ER) visit. You say that you should not 
be responsible to pay a copayment that only incurred due to the error of a medical professional. 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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for each emergency room (ER) visit. This item/service falls 
within the emergency care 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 each 
emergency room (ER) visit provided on June 06, 2023, to June 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on April 26, 2023.  
 
You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because the requested 
foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on April 26, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service December 30, 
2022, to January 16, 2022. You asked the Plan to pay for the billed services . You say that the NOA was received. The Plan denied your 
request. The Plan says the NOA was not received timely. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 30, 2022. The documentation in the case file does not show that 
an NOA was submitted. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health care billed for dates of 
service December 30, 2022, to January 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the telehealth visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visits. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says these services are available with in-network 
providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visits to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 
8, 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 October 26, 2022. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on May 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network intermittent urinary catheter 
provided on February 23, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network intermittent urinary catheter. You say that you 
are usually charged much less for these items. This new bill is way too expensive and feels like its been 
charged as an out-of-network 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 20% 
coinsurance for prosthetic devices and related supplies.  
 The allowed amount of this item is $3,718.80, resulting in a coinsurance amount of $743.76 ($3,718.80 x 20% 
= $743.76). 
 
You have been asked to pay a $743.76 coinsurance for an in-network intermittent urinary catheter. This 
item/service falls within the prosthetic devices and related supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for an in-network intermittent urinary catheter provided on February 23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067) and the take home 
supply of methadone (G2078) provided on April 17, 2023, by an OON provider.   
You asked the Plan to pay for the medication assisted treatment and the take home supply of methadone. You 
say that you are requesting reconsideration of the denied claim. The Plan denied your request. The Plan says 
the service was not authorized. 
 
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 the medication assisted treatment (G2067) and the 
take home supply of methadone (G2078) provided on April 17, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hemisection (D3920) provided on April 27, 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 the services denied correctly as they do not fall 
within your 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 pay for a 
hemisection (D3920) provided on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation and full mouth 
debridement (D0180, D4355) provided on May 16, 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 the services denied correctly as they do not fall 
within your Plan benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a comprehensive periodontal 
evaluation and full mouth debridement (D0180, D4355) provided on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on November 
10, 2022. 
 
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 April 19, 2023. 
Therefore, we decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on 
November 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of new or replacement of permanent 
pacemaker with transvenous electrode(s); atrial and ventricular (33208). 
 
You asked the Plan to pre-approve insertion of new or replacement of permanent pacemaker with transvenous 
electrode(s); atrial and ventricular. You say that this is medically necessary. The Plan denied your request. The 
Plan says the documentation does not support pacemaker placement criteria 
 
The Plan follows Medicare rules. Medicare rules say that implanted permanent single chamber or dual chamber 
cardiac pacemakers can be 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 insertion of new or replacement of 
permanent pacemaker with transvenous electrode(s); atrial and ventricular. Our reviewer says that there is 
insufficient documentation to support the medical necessity for insertion of a pacemaker in this enrollees 
clinical management. Our physician reviewer found while the enrollee has a history of left bundle branch block 
and dizziness, there is no evidence of symptomatic bradycardia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of new or replacement of permanent pacemaker with transvenous 
electrode(s); atrial and ventricular have not been met. Therefore, we decided that the Plan does not have to pre-
approve insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and 
ventricular (33208).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling and scaling in presence of severe inflammation 
(D2330, D4346) provided on April 18, 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 the services denied correctly as they do not fall 
within your 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 pay for a filling 
and scaling in presence of severe inflammation (D2330, D4346) provided on April 18, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve the drug. You say that giving the enrollee a trail of immunotherapy drugs 
with atezolizumab is appropriate. The Plan denied your request. The Plan says Tecentriq is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that 
Tecentriq is not medically necessary. Our physician reviewer found that the requested use of Tecentriq is not 
FDA-approved. Tecentriq is also not supported by one of the major drug compendia or by clinical research.  
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Tecentriq.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the basivertebral nerve ablation. 
 
You asked the Plan to pre-approve the basivertebral nerve ablation. You say that the basivertebral nerve 
ablation is not medically necessary. The Plan denied your request. The Plan says the intracept procedure is 
truly the only solution, as no other procedure ablates the basivertebral nerve which is the source of the 
enrollee's chronic low back pain.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the basivertebral nerve ablation. Our 
reviewer says that the basivertebral nerve ablation is not medically necessary. Our physician reviewer found 
that the requested levels do not match the radiology data. Therefore, the request is not medically reasonable and 
necessary.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the basivertebral nerve ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the basivertebral nerve ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on August 11, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that you moved out of the area and 
was told that you could still use your coverage for two months. You say that you were not aware that you only 
had coverage for urgent care and the emergency room outside of the county. The Plan denied your request. The 
Plan says that chiropractic manipulative treatment is available in network. 
 
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 chiropractic manipulative treatment provided on 
August 11, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infrared light therapy provided on February 9, 2023. 
 
You asked the Plan to pay for Infrared light therapy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Infrared therapy is considered not reasonable and necessary by 
Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. 
 
 We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for Infrared light therapy provided on February 9, 2023.