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

 
We decided that the Plan does not have to pay for the duplex scan provided on July 8, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the duplex scan (93986). You say that you could not get a referral from the 
enrollee's PCP. The Plan denied your request. The Plan says you did not request 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 has network providers 
available who can provide the services 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 these services. Therefore, we decided that the 
Plan does not have to pay for the duplex scan provided on July 8, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on June 22, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing 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. 
 
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 skilled nursing services provided on June 22, 2020 
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 26, 2020 by a non-
network provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-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 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 March 26, 2020 
by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 24, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that in most 
cases care the enrollee receives from an out-of-network provider 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 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 
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 physician's services provided on June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve eye consultation exam. You say that this doctor helped your condition 
immensely, while every other doctor has ignored it. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this provider is out-of-network with the Plan and you can be 
treated by an in-network specialist. 
 
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 medical services 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 the services provided on August 6, 2018. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until March 5, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on August 6, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 you by an out-of-network provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide an additional 6 months of supplies. 
 
You asked the Plan to provide an additional 6 months of supplies for the continuous glucose monitor. You say 
that the enrollee needs a CGM and supplies. The Plan denied your request. The Plan says the enrollee is 
required to be re-evaluated after 6 months. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The rules say every 6 months following the initial prescription of the 
CGM the treating physician has an evaluation with the enrollee to assess adherence to the CGM regimen and 
diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of an 
additional 6 months of continuous glucose monitor supplies have not been met. Therefore, we decided that the 
Plan does not have to provide an additional 6 months of supplies for the CGM.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307, G0480) provided on February 
11, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory 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 laboratory services (80307, G0480) provided 
on February 11, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that please reconsider the authorization for 
incontinence pads and pull ups. The enrollee is on a very limited income and you desperately needs these items 
for health, hygiene and welfare. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the eyewear. 
 
You asked the Plan to pre-approve the eyewear. You say that the glasses are necessary. The Plan denied your 
request. The Plan says you exhausted your benefit and you also did not need the glasses as a result of cataract 
surgery. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglasses or contact lenses after each cataract surgery that includes 
insertion of an intraocular lens (If you have two separate cataract operations, you cannot reserve the benefit 
after the first surgery and purchase two eyeglasses after the second surgery.) Your supplemental vision benefit 
 
 
eyewear allowance is $250 once every twenty-four (24) months.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eyewear have not been met. You previously received glasses on August 26, 2019. Your benefit 
allows a $250 eyewear allowance every two (2) years. Therefore, your supplemental vision benefit has been 
exhausted and will not start over until August 27, 2021. Furthermore, you cannot use your medical vision 
benefit for the glasses because you did not have cataract surgery. Therefore, we decided that the Plan does not 
have to pre-approve the eyewear.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on May 29, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you received periodontal maintenance. You say 
that this service is a preventive dental service. You also say that this service is to maintain the health of your 
gums. The Plan denied your request. The Plan says on preventive dental services are covered. The Plan says 
that periodontal maintenance is not a preventive dental service as it is used to treat a specific, diagnosed 
condition. 
 
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 periodontal maintenance is not 
among those covered under this benefit as it is not a preventive dental service. Therefore, we decided that the 
Plan does not have to pay for the periodontal maintenance (D4910) provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided. 
 
You asked the Plan to pay for this service. You say that the Plan should cover this service. The Plan denied 
your request. The Plan says you did not have a referral from your PCP. 
 
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 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 specialist services provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that you should 
owe much less. The Plan denied your request. The Plan says the claims were processed correctly and you are 
being charged the correct 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 $360 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay. Therefore, you are responsible to pay a 
$360 (copayment) for days 1-2 . $360 (copayment) x 2 (inpatient days) = $720. 
 
You have been asked to pay the total copayment amount of $720 for an inpatient hospital stay. An inpatient 
hospital stay 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. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 21, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you had a sore on the roof of your mouth. You 
say that it was bleeding for over a week. You also say that this should be considered an emergency 
appointment. The Plan denied your request. The Plan says 1 limited oral evaluation per plan year is covered. 
The Plan also says the frequency limit has been exceeded. 
 
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 frequency limit of 1 limited oral 
evaluation per plan year has been exceeded. The record shows that you received this service on February 12, 
2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) 
provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit services received on June 8, 
2020 and July 6, 2020. 
 
You asked the Plan to waive the copayment for the office visit services. You say that you were under the 
impression that all copayments would be waived. The Plan denied your request. The Plan says the services 
have been processed correctly per your plan benefits. 
 
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 specialist office visits.  
 
Review of the file shows that your copayment requirement for specialist office visits are $45. However, the 
allowed amount for the services received on July 6, 2020 was $43.59. Since this is less than your copayment 
requirement you were charged the lesser amount for this date of service. 
 
You have been asked to pay a $45 copayment and a $43.59 copayment for the office visit services. The office 
visit services fall within the physician/practitioner 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 office visit services received on June 8, 2020 and July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of a mandibular resin partial denture base (D5611) 
provided. 
 
You asked the Plan to pay for the repair of a mandibular resin partial denture base. You say that your lower 
denture broke and you needed it fixed. You also say that if your denture had not been fixed, your general health 
would have been affected. The Plan denied your request. The Plan says this service is not a covered benefit 
under your dental plan. 
 
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 pay for the repair 
of a mandibular resin partial denture base (D5611) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided by a participating 
provider on September 25, 2014, to February 23, 2016. 
 
You asked the Plan to waive the copayment for an office visit. You say that due to Covid-19 you cannot afford 
these The Plan denied your request. The Plan says the correct copayments have 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 
copayment, a $15 copayment and a $10 copayment for physician/practitioner services/primary care physician.  
 
You have been asked to pay a $20 copayment, a $15 copayment and a $10 copayment for an office visit. The 
total amount you are being asked to pay is $110 ($20 + $20 + $15 + $15 + $15 + $15 + $1= $110). An office 
visit falls within the physician/practitioner services/primary care physician 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 an office visit provided by a participating provider on September 25, 
2014, to February 23, 2016.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance. 
 
You asked the Plan to pre-approve the periodontal maintenance. The Plan denied your request. The Plan says 
this service is not a covered benefit under the enrollee's dental plan. 
 
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 
periodontal maintenance.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic mammography provided on June 2, 2020. 
 
You asked the Plan to pay for diagnostic mammography, professional component (77065). You say that the 
Plan should pay for two services. The Plan denied your request. The Plan says the allowed MUE value of 1 was 
exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 77065 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of diagnostic mammography (77065) have not 
been met. Therefore, we decided that the Plan does not have to pay for diagnostic mammography provided on 
June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Zoster (shingles) vaccine (HZV), recombinant, subunit, 
adjuvanted, for intramuscular use (90750) provided. 
 
You asked the Plan to pay for the shingles zoster. You say that you are appealing the decision to deny and have 
provided all the papers that you have. The Plan denied your request. The Plan says the shingles shot is not 
covered under Part B benefits. The shingles shot is only covered under the Part D prescription drug benefit.  
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pay for Zoster (shingles) vaccine (HZV), recombinant, subunit, adjuvanted, for 
intramuscular use (90750) provided.