Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110), panoramic x-ray 
(D0330), and comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve the maxillary complete denture, panoramic x-ray, and comprehensive oral 
evaluation. You say that your upper denture has cracked and needs to be replaced. You also say that you are 
overwhelmed by what these services will cost. The Plan denied your request. The Plan says maxillary complete 
denture is not a covered benefit. The Plan also says that your panoramic x-ray and comprehensive oral 
evaluation benefits have exceeded the frequency limitations. 
 
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, maxillary complete dentures are not 
covered under this benefit. The contract also says that oral exams are limited to once every 6 months, and 
panoramic x-rays are limited to once every 36 months. The record shows that you received a panoramic x-ray 
(D0330) and comprehensive oral evaluation (D0150) on May 27, 2020 and your oral exams and panoramic x-
rays benefits have been. Therefore, we decided that the Plan does not have to pre-approve a maxillary complete 
denture (D5110), panoramic x-ray (D0330), and comprehensive oral evaluation (D0150).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99213) to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are available providers within the network that can provide the requested services.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office visits (99213) to be rendered by the out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be rendered by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are available providers within the network that 
can provide the requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be rendered by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services (98940) to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve OON chiropractic services. You say that you have been seeing this provider 
and would like to continue because he was recommended to you by friends. The Plan denied your request. The 
Plan says the requested services are 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 
the chiropractic services (98940) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom ramp (E1399). 
 
You asked the Plan to pre-approve the ramp. You say that you need the ramp because you are wheelchair 
bound. The Plan denied your request. The Plan says this item is a convenience item and is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the custom ramp (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a new patient visit with an out-of-network tertiary 
Orthopedic Surgeon. 
 
You asked the Plan to pre-approve a new patient visit with an out-of-network tertiary Orthopedic Surgeon. You 
say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the 
requested services can provided by an in-network tertiary Orthopedic Surgeon. 
 
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 
a new patient visit with an out-of-network tertiary Orthopedic Surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over-bed table (E0274). 
 
You asked the Plan to pre-approve an over-bed table. You say that you cannot get out of bed to eat. You are 
required to drink a lot of water and the only table you have for the water is too low. It would be easier for you 
to get your medication. The Plan denied your request. The Plan says this is a convenience item and is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an over-bed table (E0274).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the professional components of the laboratory testing 
provided from February 4, 2020 to February 7, 2020. 
 
You asked the Plan to pay for the lab testing professional component. You say that these codes should be paid. 
The Plan denied your request. The Plan says these codes are not payable when billed for the professional 
component only. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The codes at issue are not payable on the Physician Fee Schedule but have a PC/TC indicator of "9" meaning 
that the concept of professional/technical components does not apply. These services are paid in the Clinical 
Laboratory Fee Schedule and only have a fee for the global service, and no breakdown for PC/TC of the 
service. This means that payment cannot be made for these codes when billed with the modifier -26. Therefore, 
we decided that the Plan does not have to pay for the professional components of the laboratory testing 
provided from February 4, 2020 to February 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair purchased on February 23, 2020 from an out-of-
network provider. 
 
You asked the Plan to pay for the lift chair. You say that you found a chair that worked from an out-of-network 
provider but none of the Plan's approved providers could order that chair specifically. The Plan denied your 
request. The Plan says you do not have out-of-network benefits. 
 
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 lift chair purchased on February 23, 2020 from 
an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on October 25, 2019. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you paid $150. You 
say that no one told you it would be more than that. The Plan denied your request. The Plan says the correct 
coinsurance has been applied. 
 
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 durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $299.91. The total amount you are being asked to pay is $59.98 ($299.91 x 20% = 
$59.98). Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on 
October 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ride provided on November 
7, 2019. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you were unaware that you 
would have to pay such a hefty copayment to be transported and you had no other means of transportation. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $195 
copayment for each one-way Medicare-covered ground trip.  
 
You have been asked to pay a $195 copayment for the ambulance ride. The ambulance ride falls within the 
Ambulance Services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance ride provided on November 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on November 15, 2019.
You asked the Plan to pay for the drug testing. You say that this is medically necessary testing. The Plan denied your request. The Plan says there is no established relationship between the ordering provider and the enrollee.
The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by the treating physician. The file contains no lab requisition form for this testing. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift mechanism (E0627) unlisted special service (99199) purchased January 28, 2020 from an out-of-network, non-certified Medicare provider.
You asked the Plan to pay for the seat lift mechanism and unlisted service. You say that you purchased the chair because it suited your needs. You have attached copies of the claim along with the doctor's orders and a copy of your Medicare card. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism and unlisted service have not been met. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0627) unlisted special service (99199) purchased January 28, 2020 from an out-of-network, non-certified Medicare provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hip injection provided on February 11, 
2020. 
 
You asked the Plan to waive the copayment for the hip injection. You say that you were not informed that you 
made an appointment at a hospital outpatient facility. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
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 $300 
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges. For this date of 
service, you have been asked to pay the allowed amount of the claim because this amount is less than the $300 
copayment for the hip injection. 
 
You have been asked to pay a $261.80 copayment for the hip injection. The hip injection falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. The record shows you were billed by the 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 hip injection provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cerebral perfusion analysis (0042T) rendered by the out 
of network (OON) provider on December 4, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network 
provider, without prior authorization. 
 
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the cerebral perfusion analysis (0042T) rendered by the out of network (OON) provider on 
December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the SPECT test, the stress test, the medical supply, and the Part B injection provided on March 24. 2020.
You asked the Plan to reduce the cost share for the SPECT test, the stress test, the medical supply, and the Part B injection. You say that you should only be charged a $100 copayment for the stress test. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for each in-network Medicare-covered radiological diagnostic services, a $40 copayment for each in-network Medicare-covered non-radiological diagnostic services, 20% coinsurance each in-network Medicare-covered medical supply, and a $50 copayment for each in-network Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer. You have been asked to pay a total of $238.68 for the SPECT test, the stress test, the medical supply, and the Part B injection. The SPECT test, the stress test, and the medical supply fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Part B injection falls within the "Medicare Part B Prescription Drugs" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment/Coinsurance
Member Liability
March 24, 2020
SPECT test
$317.33
$100
$100
March 24, 2020
Stress test
$68.47
$40
$40
March 24, 2020
Medical supply
$243.40
20%
$48.68
March 24, 2020
Part B injection
$236.88
$50
$50
Total
$238.68
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 cost share for the SPECT test, the stress test, the medical supply, and the Part B injection provided on March 24. 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on November 6, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network 
deficiency for these services. 
 
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 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 to the enrollee by an out-of-network provider 
on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for home health services provided on February 
3, 2020. 
 
You asked the Plan to waive the deductible for home health services. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 
being charged the correct amount. 
 
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 there is a $500 deductible for home health agency care.  
 
The enrollee received home health services on February 3, 2020. The record shows that the enrollee had only 
paid $201.59 toward the $500 deductible prior to receiving the services. Therefore, the enrollee is responsible 
to pay the allowed amount of $127.40. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category home health 
agency care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible for home health agency care. This cost sharing is a contractual obligation that had not been met at 
the time home health services were received on February 3, 2020. Therefore, we decided that the Plan does not 
have to waive the deductible for home health services provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit and laboratory services 
rendered by the out of network (OON) provider on December 4, 2019. 
 
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 services were rendered by an out of 
network provider, without prior authorization. 
 
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 hospital outpatient clinic visit and laboratory services rendered by the out of 
network (OON) provider on December 4, 2019.