Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a compression garment and the compression controller 
to be provided by an OON provider.  
 
You asked the Plan to pre-approve a compression garment and the compression controller. You say that you 
are requesting reconsideration of the denied items. The Plan denied your request. The Plan says the items were 
not approved. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a compression 
garment and the compression controller to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 20, 
2023, through January 21, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the 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 does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) with dizziness described as the 
room spinning and a fall into a wall without losing consciousness. Her vital signs were stable. The history and 
initial workup strongly suggested benign paroxysmal positional vertigo confirmed after the workup was 
completed, and she was treated with meclizine. Based on the low complexity, low severity of the presentation, 
it was not expected that the enrollee would have required hospital care that would have likely crossed 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 not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from January 20, 2023, through January 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341). 
 
You asked the Plan to pre-approve 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 November 8, 2021 and 
November 11, 2021. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and 
root planing (D4341).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided on February 27, 2023, to 
February 28, 2023. 
 
You asked the Plan to pay for the inpatient care. You say that you are appealing the denial with supporting 
documentation. 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 inpatient care 
provided on February 27, 2023, to February 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient surgery on May 08, 2023.  
 
You asked the Plan to waive the cost share for outpatient surgery. You say that the copayment seems 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 10% for each Medicare-covered outpatient hospital facility visit. Covered services include but are 
not limited to the following and cost sharing may apply services in an emergency department or outpatient 
clinic, such as observation services or outpatient surgery. The provider billed in the amount of $3,222.05 and 
the allowed amount is $80.51. The plan paid $285.10. There is $482.27 deductible and $32.32 coinsurance. For 
the service it's, $482.27 + $32.32 = $514.59. Therefore, results in the total cost sharing amount of $514.59. 
 
The enrollee has been asked to pay a $514.59 cost share for outpatient surgery. This item/service falls within 
the outpatient hospital services 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 waive the cost share for 
outpatient surgery on May 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient home visit, and debridement of nails provided 
on April 15, 2023. 
 
You asked the Plan to pay for a new patient home visit, and debridement of nails. 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 a new patient home 
visit, and debridement of nails provided on April 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on May 22, 2023, to May 23, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that this amount is 
too high for you to afford. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for inpatient hospital care. 
 
You have been asked to pay a $325 copayment for an in-network acute inpatient stay. This item/service falls 
within the inpatient hospital 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. However, since the allowed amount is less than the standard copayment, you 
only owe $305. Therefore, we decided that the Plan does not have to waive the copayment for an in-network 
acute inpatient stay provided on May 22, 2023, to May 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on April 20, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period.  
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the ED services provided on April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that HBOT is covered for specific indications only. 
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show that you do not have a 
history of complications from radiation therapy resulting in bone death (osteoradionecrosis). You do not have a 
condition for which Medicare covers HBOT. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the chiropractic manipulative treatment. You say that the office is 
convenient for the enrollee. You say that the office hours work with the enrollee's schedule. 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 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 
chiropractic manipulative treatment to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87798 and 87481 provided on June 14, 
2023. 
 
You asked the Plan to pay for procedure codes 87798 and 87481. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87798 and 87481 provided on June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental crowns for teeth #22 through #27. 
 
You asked the Plan to pre-approve dental crowns. You say that this is medically necessary. The Plan denied 
your request. The Plan says restoration or maintenance of occlusion and replacing tooth structures lost as a 
result of abrasion, attrition, erosion or abfraction are not covered services. 
 
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 
dental crowns for teeth #22 through #27.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you would prefer not to be scheduled with that 
provider. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit and debridement provided on March 06, 2023, to 
April 10, 2023. 
 
You asked the Plan to pay for home visit and debridement. You say that you are appealing the claim payment 
denial. 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 home visit and 
debridement provided on March 06, 2023, to April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) for tooth 19 and 
abutment supported porcelain/ceramic crown (D6058) for tooth 19. 
 
You asked the Plan to pre-approve the dental services. You say that you understand that you only spent $3,690 
and that service added up to an additional $1,245. Therefore, you request that these services be approved. 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 February 10, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) for 
tooth 19 and abutment supported porcelain/ceramic crown (D6058) for tooth 19.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for the radiation therapy provided on February 7, 2023. 
 
You asked the Plan to reduce the copayment for the radiation therapy. You say that you should only have a $35 
copayment. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $35 copayment for Medicare-covered therapeutic 
radiology. 
 
The Plan says you must pay a $125 copayment for the radiation therapy. Based on the Plan contract, however, 
you cannot be asked to pay more than a $35 copayment for the radiation therapy. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies benefit category. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan has 
to reduce the copayment for the radiation therapy provided on February 7, 2023.  
 
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 pre-approve a gastroenterology consultation and follow up visits to 
be provided by an OON provider.  
 
You asked the Plan to pre-approve a gastroenterology consultation and follow up visits. You say that the 
service is medically necessary. The Plan denied your request. The Plan says this service is 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 visit to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the revascularization of artery of leg with angioplasty 
(37222). 
 
You asked the Plan to pre-approve the revascularization of artery of leg with angioplasty. You say that the 
enrollee does not meet criteria for coverage. The Plan denied your request. The Plan says the enrollee needs 
this procedure to return to a better quality of life. 
 
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 revascularization of artery of leg 
with angioplasty. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee has a history and imaging findings of 
lumbar spine disease that could explain the enrollees bilateral short distance walking limitation. The symptoms are disproportionate to the degree of vascular findings. There is documentation that the enrollee is negative for 
claudication. The Ankle Brachial Index (ABIs) are normal bilaterally. No pulse examination is 
documented. Intervention on the right would not be expected to address bilateral symptoms and would be 
unlikely to provide any meaningful improvement in quality of life. There is no suggestion of limb threat in the 
medical 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 the revascularization of artery of leg with angioplasty have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the revascularization of artery of leg with 
angioplasty (37222).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction for tooth #13 and dentures. 
 
You asked the Plan to pre-approve 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 pre-approve an 
extraction for tooth #13 and dentures.