Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 9, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for facility provided self-administered drugs administered from 
May 28, 2020, to May 30, 2020. 
 
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that these drugs were 
prescribed by your doctor. The Plan denied your request. The Plan says self-administered drugs must be 
submitted to your Part D carrier. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for facility provided self-
administered drugs administered from May 28, 2020, to May 30, 2020.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult day care services, per diem (S5102). 
 
You asked the Plan to pre-approve the adult day care services. You say that you have a hard time monitoring 
your medications. You would benefit from 2nd home to coordinate and transport you to doctor appointments 
and to check in with you and monitor your medication intake. The Plan denied your request. The Plan says 
custodial services are not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Custodial care is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the adult day care services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve adult day care services, per diem (S5102).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided 
with an out-of-network provider. 
 
You asked the Plan to waive the copayment for office visit. You say that you should be paying the in-network 
cost share. The Plan denied your request. The Plan says the cost share is correct. 
 
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 
copayment for out-of-network for Physician/Practitioner Services, Including Doctor?s Office Visits.  
 
You have been asked to pay a $20 copayment for out-of-network for office visit. This service falls within the 
Physician/Practitioner Services, Including Doctor?s Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for office visit provided with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2 retainer crowns (D6750), 2 core build ups (D2950), 3 
pontics (D6240), and a gingivectomy (D4211) provided on August 3, 2020. 
 
You asked the Plan to pay for the dental services. You say that the dental office led you to believe that all of 
the services were already approved. You say that you thought at least part of this claim would be covered. You 
also say that you have paid the provider $1,000 and will cost you $1,000 per month. The Plan denied your 
request. The Plan says the services you received are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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. The record shows that you signed a treatment plan that shows there is 
no coverage for retainer crowns, core build up, pontics, or ginivectomy procedures and that you would be fully 
responsible for the charges for these services. Therefore, we decided that the Plan does not have to pay for 2 
retainer crowns (D6750), 2 core build ups (D2950), 3 pontics (D6240), and a gingivectomy (D4211) provided 
on August 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 24, 2020, by an 
OON provider. 
 
You asked the Plan to pay for a mental health therapy session. You say that these services are medically 
necessary. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 has network providers 
available who can provide 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 medical services provided on August 24, 2020, 
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the head CT provided on February 19, 
2020. 
 
You asked the Plan to waive the copayment for the head CT. You say that you were at a imaging center near 
the hospital. The Plan denied your request. The Plan says the imaging services are owned and billed by the 
hospital. 
 
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 $225 
copayment for outpatient advanced imaging services.  
 
The procedure approved amount was $101.93. You have been asked to pay a $101.93, less than your 
copayment, for the head CT. The head CT falls within the outpatient advanced imaging services benefit 
category. The services were provided in an outpatient hospital facility. 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 head CT provided on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 8, 2020, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that this claim is related to an initial emergency 
room visit. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. Medical documentation in the case record does not support that the items/services 
provided on July 8, 2020, were related to a prior emergency room visit. 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 medical services provided on July 8, 2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cologuard test. 
 
You asked the Plan to pre-approve a Cologuard test. You say that the requested test is based on your history of 
irritable bowel syndrome, age, and current problems. The Plan denied your request. The Plan says the testing is 
necessary and reasonable every 3 years. 
 
The Plan must follow Medicare rules. Medicare rules say that colorectal cancer screening tests are only covered 
under certain medical indications.  
 
We looked at the file and Medicare rules. The records show that you last received the requested test in 2018. 
The Cologuard test is only covered once every 3 years. 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 pre-approve a 
Cologuard test.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services (99601) provided November 19, 
2019 to December 3, 2019. 
 
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this service is not eligible for Medicare payment. 
 
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 99601 is not supported in the medical record. Specifically, per the 2019 Year National 
Physician Fee Schedule, CPT code 99601 is marked with a status of "I" and is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion services have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion services (99601) 
provided November 19, 2019 to December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the naturopathic services provided on June 11, 2020. 
 
You asked the Plan to pay for the naturopathic services. You say that you have no other choice in pain 
management. The Plan denied your request. The Plan says this service is not covered under your Plan benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for the naturopathic services provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 2, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says 
that these services were self-referred. 
 
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 has network providers 
available who can provide 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 an office visit provided on July 2, 2020 by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 13, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the providers close working relationship with the 
dental practice gives him a greater understanding. The Plan denied your request. The Plan says there are in-
network providers who can provide care. 
 
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 in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on February 13, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiography provided on March 
26, 2020 and June 8, 2020. 
 
You asked the Plan to waive the copayment for the echocardiography. You say that both procedures were 
echocardiograms but were coded different resulting in a difference of charges. You say that you want these 
bills resolved. The Plan denied your request. The Plan says the copayments applied 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 $110 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a free-standing facility. Examples include, but are not limited to, specialized scans, CT, 
SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional 
radiological procedures (myelogram, cystogram, angiogram, and barium studies). 
  
You have been asked to pay a total of $206.77 for the echocardiography provided on March 26, 2020 and June 
8, 2020.  
 
Date of Service Service Allowed Amount Standard Copayment Member Liability 
March 26, 2020 Echocardiography $203.31 $110 $110 
June 8, 2020 Echocardiography $96.77 $110 $96.77 
TOTAL:    $206.77 
 
 
The echocardiography falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the echocardiography provided 
on March 26, 2020 and June 8, 2020.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve the home health services. 
 
You asked the Plan to pre-approve home health services. You say that you need home health services. The Plan 
denied your request. The Plan says that the rules for home health services have not been met. 
 
The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing 
coverage of home care services.  
 
There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services 
at issue in this appeal. Therefore, we decided that the Plan has to pre-approve the home health services.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical information received does not support the medical necessity of the 
service requested. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled 
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on May 10, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied 
your request. The Plan says due to the enrollee's hospice status on the date of service, this claim should be 
submitted to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on May 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted 
out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
services you received.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on April 
27, 2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 80307 and G0482 are not supported in the medical record. Specifically, laboratory 
results were not submitted for the billed date of service to support the services billed. Based on this 
information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on April 27, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on June 24, 2020. 
 
You asked the Plan to pay for retail hearing aids. You say that the Plan should cover these hearing aids. The 
Plan denied your request. The Plan says you did not follow the rules of your Plan contract when purchasing 
hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plan's hearing aid provider. This provider is not in this network.   
Therefore, we decided that the Plan does not have to pay for hearing aids purchased on June 24, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on February 28, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you did not know which provider you needed to go 
to for hearing services. The Plan denied your request. The Plan says that there is no coverage if hearing aids or 
related services are received from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when ordered directly from the in-network provider. 
 
We looked at the file and the Plan's rules. The file indicates the hearing aids were not ordered directly from the in-network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on 
February 28, 2020.