Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sixty minutes of psychotherapy (90837) provided on 
February 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that medically necessary services were rendered in good 
faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 sixty minutes of psychotherapy (90837) 
provided on February 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Xolair injection you received on April 
28, 2020. 
 
You asked the Plan to waive the coinsurance for the Xolair injection. You say that you have gotten this 
injection before and it didn't cost this much. The Plan denied your request. The Plan says you were charged this 
coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B covered drugs.  
 
You have been asked to pay 20% coinsurance for the Xolair injection.  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 the Xolair injection you received on April 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 17, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says has to pay 
for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-
approved 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory 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 laboratory services provided on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services you had on August 3, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that you had a lab test on July 21, 
2020 that was for the same thing.  You said you just had to submit an additional specimen.  You said that 
because this was all part of one test, you should not have to pay a second lab copayment. The Plan denied your 
request. The Plan says you were assessed this copayment 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 $10 
copayment per day for lab services.  
 
You have been asked to pay a $10 copayment per day for the lab services. The medical records form July 21, 
2020 indicate that your lab specimen was sent to test for c. difficile toxin, leukocytes in the stool, and screening 
for ova and parasites.  However, the lab specimen sent to the lab on August 3, 2020, was done to test pancreatic 
elastase levels.  These were not part of the same test, but were two distinct lab services.  That is why a separate 
copayment is applicable for the August 3, 2020, date of service. 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 lab services you had on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit. 
 
You asked the Plan to waive the copayment for the office visit.. You say that you were seen for your annual 
routine physical, so this visit should be covered in full. The Plan denied your request. The Plan says you 
received services in addition to your routine physical, so the copayment was 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 $20 
copayment for primary care visits.  
 
You have been asked to pay a $20 copayment for the office visit. Your Evidence of Coverage states that if you 
receive services that address a medical condition during the same office visit as your annual physical, 
additional cost-share may apply.  The medical records from this visit clearly indicate that your doctor evaluated 
and counseled you in relation to your diabetes condition in addition to the routine annual physical services.  
That is why a primary care 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 office visit you had.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for room and board services provided. 
 
You asked the Plan to pay for the room and board services. The Plan denied your request. The Plan says 
providers must bill Original Medicare for all hospice and non-hospice-related services covered by Medicare 
Parts A and B. 
 
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 room and board services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve new dentures. 
 
You asked the Plan to pre-approve new dentures. You say that your dentures are broken, and you need new 
ones. The Plan denied your request. The Plan says this is a supplemental benefit that is only covered every 5 
years. 
 
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, your denture benefit is not available at 
this time. Therefore, we decided that the Plan does not have to pre-approve new dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that your old 
dentures are no longer sufficient, and you cannot pay for new dentures. The Plan denied your request. The Plan 
says these services exceed the maximum count allowed per period. 
 
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, complete maxillary denture (D5110) 
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record 
shows that you received a complete maxillary denture and a complete mandibular denture, 
and your maxillary and mandibular denture benefits have been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture 
(D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office or other outpatient visit (99203) 
provided, by an out of network (OON) provider. 
 
You asked the Plan to pay for the new patient office or other outpatient 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 by the facility or the provider; therefore, payment has been correctly denied. 
 
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 new patient office or other outpatient visit 
(99203), by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions of tooth #'s 5, 6, 7, 8, 11, 12, 18, 22, and 23. 
 
You asked the Plan to pre-approve the extractions. You say that it is medically necessary for the enrollee's teeth 
to be extracted. The Plan denied your request. The Plan says your $750 plan maximum has been met for the 
year. 
 
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, there is a maximum plan benefit 
coverage amount of $750 per year. The enrollee is responsible for any cost above the $750 maximum. The 
record shows that the enrollee was approved for 5 extractions, and the enrollee's 
maximum plan benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve 
extractions of tooth #'s 5, 6, 7, 8, 11, 12, 18, 22, and 23.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the stay was approved as observation level of care. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found with the recurrent nature of the diverticular bleed, it was reasonable to expect that a patient with 
recurrent bleeding would require admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service is not 
covered. 
 
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. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that 
inpatient care 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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the ER, with fever and tachycardia. His physical 
exam was unremarkable, and labs revealed WBC 6.8 with an abnormal urinalysis. He was treated with IV 
fluids and IV Ceftriaxone. His condition stabilized and improved and he was discharged home. 
The record showed that at the time of inpatient admission the admitting physician reasonably expected that the 
enrollee's necessary hospital care (including earlier ED and/or observation care) would span 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided.  
 
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 waive the copayment for a physician visit (99213). 
 
You asked the Plan to waive the copayment for a physician visit. You say that this copayment should not have 
been charged as it was covered under your payment of the inpatient fee. The Plan denied your request. The 
Plan says the correct copayment was 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 $45 
copayment for consultation, diagnosis, and treatment by a specialist. Your contract also says that, when 
formally admitted to the hospital with a doctor?s order, the day before the enrollee is discharged is the last 
inpatient day. 
 
In this case, you confirm that you were discharged. Therefor, You have been asked to pay a $45 copayment 
for a physician visit. 
A physician visit 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 a physician visit (99213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 27, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 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 July 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services (97161, 97110, 97802) 
provided, by an out of network (OON) provider. 
 
You asked the Plan to pay for physical therapy services. 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 
by the facility or the provider; therefore, payment has been correctly denied. 
 
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 physical therapy services (97161, 97110, 
97802) 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 the office visit with drug test (99214, 80307) provided, by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit with drug test. You say that you would like this claim reprocessed 
and approved for payment based on the medical records. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 office visit with drug test (99214, 80307) 
provided, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power lift chair (E0627) provided, 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the power lift chair. You say that the OON provider provided a payment plan to 
your liking. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or 
the provider; therefore, payment has been correctly denied. 
 
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 power lift chair (E0627) 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 the subsequent nursing facility visit (99310) provided, by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 subsequent nursing facility visit (99310) 
provided, by an out of network (OON) provider.