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

 
We decided that the Plan does not have to pay for the consultation and extraction provided on April 28, 2020. 
 
You asked the Plan to pay for the consultation and extraction. You say that you were led to believe that part of 
the services would be covered by your insurance. The Plan denied your request. The Plan says these services 
are not allowed because they were performed by a provider who has chosen to opt 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 the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
consultation and extraction provided on April 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided. 
 
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the 
charges because you were told that they would not be charged for the supplies. 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 20% 
coinsurance for DME and related supplies.  
 
You received DME and related supplies from, for a total of 7 deliveries. 
Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount per each 
date of service is $122.33 and 20% of that is $24.47. The total amount you owe is: $24.47 (coinsurance) x 7 
(deliveries) = $171.29. 
 
You have been asked to pay the total coinsurance amount of $171.29 for DME and related supplies. DME and 
related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 10, 2020. 
 
You asked the Plan to pay for 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 
physicians 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 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93000) and a physician office visit 
(99215) with your cardiologist. 
 
You asked the Plan to pay for an electrocardiogram and a physician office visit. You say that you had no way 
of understanding your provider would no longer be covered by your Plan. The Plan denied your request. The 
Plan says the 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 an 
electrocardiogram (93000) and a physician office visit (99215) with your cardiologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from June 28, 2020, to July 19, 
2019. 
 
You asked the Plan to pay for the dental services provided on June 28, 2019 and July 19, 2020. You say that 
the provider in this case is listed in the Provider Directory. You also say that the services should be covered. 
The Plan denied your request. The Plan says there is an annual maximum of $2,000. The Plan says that the 
annual maximum 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, there is an annual maximum benefit of 
$2,000. The record shows that the annual maximum benefit has been exceeded. 
 
 
 
 
 
 
 
 
 
 
Date of Service Total Charge Plan Paid Your Responsibility 
8/1/2019 $1,300 $799 $0 
12/5/2019 $165 $124 $0 
4/5/2019 $190 $190 $0 
6/6/2019 $225 $225 $0 
6/14/2019 $225 $225 $0 
6/21/2019 $225 $225 $0 
6/28/2019 $225 $212 $13 
7/19/2019 $120 $0 $120 
TOTAL:    
 
Therefore, we decided that the Plan does not have to pay for the dental services provided from June 28, 2020, 
to July 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NEUPRO patches. 
 
You asked the Plan to pre-approve the NEUPRO patches. You say that these are medically necessary. The Plan 
denied your request. The Plan says the requested items are self-administered and cannot be covered by 
Medicare Part B. 
 
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 pre-approve NEUPRO patches.  
 
Benefits for the NEUPRO patches 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for an inpatient stay for a total knee replacement for 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 care at the inpatient level exceeds the enrollee's needs. 
 
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 based on past medical history and underlying health conditions, it is reasonable to admit the 
enrollee after the knee replacement. 
 
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 an inpatient stay for a total knee replacement for 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a 
participating provider on June 5, 2020. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you've never been charged 
this much before. 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 15% 
coinsurance for outpatient surgery/in-network.  
 
You have been asked to pay a 15% coinsurance of the allowed amount for an outpatient surgery. The total 
allowed amount is $1,760.10. The total amount you are being asked to pay is $264.02 ($1,760.10 x 15% = 
$264.02). An outpatient surgery falls within the outpatient surgery/in-network 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 an outpatient surgery provided by a participating provider on June 
5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray 
(D0220), and 2 fillings (D2932) provided. 
 
You asked the Plan to pay for the dental services. You say that you were experiencing pain due to 2 cracked 
teeth. You say that under your medical plan, your situation was considered an emergency. You say that doctors 
do not need to be in network. You say that this could be a dental emergency. You also say that the Plan should 
pay 50% of the bill. The Plan denied your request. The Plan says the services in this case are dental in nature. 
The Plan says that the provider in this case is not a network provider. The Plan says that out of network dental 
services are 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, only preventive dental services that 
you receive in network are covered. The record shows that the services you received were not preventive in 
nature. Additionally, the services were provided to you out of network. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), and 2 fillings 
(D2932) provided.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service provided on July 17, 2020. 
 
You asked the Plan to pay for the ambulance service. You say that the ambulance service was medically 
necessary. The Plan denied your request. The Plan says the enrollee could have been safely transported by 
another type of vehicle. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at this physician's review, the file, and Medicare rules. The record shows the enrollee, complaining 
of leg pain for 2 weeks, was ambulatory, conscious, stable, in no acute respiratory or cardiac distress and had 
no sign of injury, stroke, or hemorrhage. Neither oxygen nor emergency treatment was needed for transport. 
Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been 
met. Therefore, we decided that the Plan does not have to pay for the ambulance service provided on July 17, 
2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care. 
 
You asked the Plan to pre-approve home health care. You say that you need these services because you are in a 
dangerous condition. The Plan denied your request. The Plan says you have reached your full potential for 
improvement. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health care. Our reviewer says 
that the requested home health care is not medically necessary in this case. Our physician reviewer found the 
medical necessity of skilled services is not supported by the clinical documentation in the case file. The 
documentation from your providers does not support that the enrollee requires personal care services, simple 
dressing changes, assistance with medications, assistance with activities which are directly supportive of skilled 
 
 
therapy services, or provision of services incidental to personal care services. Your physician notes that you 
have not had any acute illnesses of late and that the you and your husband have been able to leave the house to 
go out to eat often, which means that you have improved significantly. Alternatives, such as outpatient physical 
therapy, could be discussed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the admission is not medically necessary. 
 
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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on November 22, 2020, with syncope and failure to thrive. He received oral medications and had stable vital 
signs. He received physical and occupational therapy in the hospital and needs moderate to maximal assist with 
functional mobility. He needs varied assist for activities of daily living. He has no skilled nursing or skilled 
therapy needs and does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the 
enrollee does not require the necessary services on an inpatient basis at the SNF level of care. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 9, 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 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist office visit (99212) and an 
ophthalmic diagnostic imaging procedure (92133) received on February 20, 2020. 
 
You asked the Plan to waive the copayments for a specialist office visit and an ophthalmic diagnostic imaging 
procedure. The Plan denied your request. The Plan says the correct copayments were 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 $40 
copayment for each specialist in-person office visit and a $50 copayment for all non-preventive (as defined by 
Medicare) diagnostic procedures and tests.  
 
You have been asked to pay a $40 copayment for a specialist office visit and a $42.76 copayment for an 
ophthalmic diagnostic imaging procedure. A specialist office visit falls within the "Physician/Practitioner 
services, including doctor's office visits" benefit category. An ophthalmic diagnostic imaging procedure falls 
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that 
you have been asked to pay less than or equal to 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 copayments for a specialist office visit (99212) and an ophthalmic 
diagnostic imaging procedure (92133) received on February 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha SureClick. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 pre-approve Repatha SureClick.  
 
Benefits for these services 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: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for laboratory services provided. 
 
You asked the Plan to hold you harmless for the laboratory services. You say that you would like 
reconsideration because you are being billed for these services. The Plan denied your request. The Plan says 
that these services are not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory services by a contract provider. The file does not show that the Plan 
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for laboratory services 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 91-mile routine transportation trip. 
 
You asked the Plan to pre-approve the requested trip. You say that you need to be able to get to this 
appointment. The Plan denied your request. The Plan says your transportation benefit does not cover trips that 
are longer than 50 miles. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation when each trip does not exceed 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a 91-mile routine transportation trip.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 12, 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 August 12, 2020.