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

We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided on May 12, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the established 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 established patient office or other outpatient 
visit (99214) provided on May 12, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit and observation 
services on May 26 to May 27, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit and observation services. You say that 
you understood that you had been admitted to the hospital. 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 $50 
copayment for emergency care. The Plan contract also says that this copayment will be waived if you are 
admitted to the hospital within 24 hours, but if you are in an observation status the copayment still applies. 
 
You have been asked to pay a $50 copayment for an emergency room visit and observation services. An 
emergency room visit and observation services fall within the "Emergency 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 emergency room visit and observation services on May 26 to May 
27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 19, 2019 by 
an OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the International Classification of Diseases 
codes are valid per CMS. The Plan denied your request. The Plan says the services were rendered by a non-
network provider. The Plan also says that the enrollee was referred by another non-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 laboratory services provided on November 19, 
2019 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services (88305, 88312, 88313, 
88311, 87101) provided on June 4, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology 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 surgical pathology services (88305, 88312, 
88313, 88311, 87101) provided on June 4, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery provided on  
March 2, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
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 outpatient surgery services provided at an in-network hospital.  
 
You have been asked to pay $644.01 ($3220.06 Plan allowed amount x 20% coinsurance) for the outpatient 
surgery provided to you at an in-network hospital. 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 outpatient surgery provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) and removal of impacted 
ear wax by washing (69209)  provided on June 10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit and ear wax removal. You say that the services were medically 
necessary. 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 outpatient office visit (99214) and removal of 
impacted ear wax by washing (69209)  provided on June 10, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on June 10, 2020. 
 
You asked the Plan to pay for the prophylaxis. You say that it would be a great help to have coverage due to 
your limited income. The Plan denied your request. The Plan says services must be performed by a contracted 
dentist. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis provided on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office outpatient visit (99213) provided on May 7, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services rendered are medically necessary. The Plan 
denied your request. The Plan says prior authorization must be obtained for 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 office outpatient visit (99213) provided on 
May 7, 2020 by an out of network (OON) provider.  
 
Your complaint about spending days on the phone with your Plan and being constantly transferred not 
resolving your issues is not a valid appeal for medical coverage. This part of your complaint is a grievance that 
must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided November 26, 2019. 
 
You asked the Plan to pay for the chest x-ray. You say that the service was medically necessary. The Plan 
denied your request. The Plan says Original Medicare is liable for payment for this service. 
 
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 a chest x-ray (71046) provided November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the shoulder orthosis provided on January 
21, 2020. 
 
You asked the Plan to waive the coinsurance for the shoulder orthosis. You say that you were never told you 
would have an additional charge for the shoulder sling. The Plan denied your request. The Plan says the 
coinsurance 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 20% of 
the total cost for Medicare-covered prosthetic devices and related supplies. 
 
You have been asked to pay $20.60, which is 20% of the allowed amount for the shoulder orthosis. The 
allowed amount is $103 (20% x $103= $20.60). The shoulder orthosis falls within the "Prosthetic devices 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 the shoulder 
orthosis provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 10, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because the physician told you that they could not treat you. 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 $25 
copayment for each specialist visit.  
 
The medical records show that you had a specialist visit provided on June 10, 2020. Therefore, you are 
responsible to pay the $25 copayment.  
 
You have been asked to pay a $25 copayment for a specialist visit. A specialist 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 specialist visit provided on June 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on June 13, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim should be submitted to Original Medicare due to the enrollee's hospice status 
at the time of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on June 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on August 10, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that the device did not work and you disagree 
with the charges. 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 on August 10, 2020. The allowed amount is $1,003.79 and 20% of that is $200.75.  
 
You have been asked to pay the total coinsurance amount of $200.75 for DME. DME falls 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 provided on August 
10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and the abutment 
supported crown (D6058) provided on June 26, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were experiencing pain. You say that you 
did not know where the pain was coming from. You also say that your dentist took x-rays to determine the 
nature of your pain. The Plan denied your request. The Plan says custom fabricated abutment is not listed as a 
covered service. The Plan says abutment supported crown is not listed as a covered service either. The Plan 
also says that any services not listed 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, the requested items or services are not 
among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment 
(D6057) and the abutment supported crown (D6058) provided on June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on June 15, 2020. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says that Medicare-
covered eye exams do not include coverage for eye refractions. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-
covered eye condition and not a routine eye exam. The file shows that part of this exam was for a refraction. 
Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis 
or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction 
provided on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on June 2, 2020. 
 
You asked the Plan to pay for the dental service. You say that the service you received is a preventive 
procedure for the detection of gum disease. The Plan denied your request. The Plan says the comprehensive 
periodontal evaluation is not listed as a covered service. The Plan also says that any services not listed 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, the requested items or services are not 
among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal 
evaluation (D0180) provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the hearing exam you had on December 
10, 2019, the chest x-ray you had on December 16, 2019, and the transthoracic echocardiography you had on 
December 16, 2019. 
 
You asked the Plan to waive the cost sharing for the hearing exam, chest x-ray, and transthoracic 
echocardiography. You say that you want the Plan to look into the charges for these services. The Plan denied 
your request. The Plan says you were charged these cost sharing amounts 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 $25 
copayment for hearing exams, A $10 copayment for x-rays, and 10% coinsurance for other diagnostic tests.  
 
You have been asked to pay a $25 copayment for the hearing exam, a $10 copayment for the chest x-ray, and 
10% coinsurance for the transthoracic echocardiography. 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 cost sharing 
for the hearing exam you had on December 10, 2019, the chest x-ray you had on December 16, 2019, and the 
transthoracic echocardiography you had on December 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one (1) additional trip for routine transportation. 
 
You asked the Plan to pre-approve an additional trip for routine transportation.. You say that you are requesting 
review of denial of services. The Plan denied your request. The Plan says you currently have one (1) trip 
remaining and you will have exceeded your benefit limit. 
 
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 a maximum of forty-eight (48) one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 49th trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve one (1) 
additional trip for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the local anesthesia in conjunction with operative 
or surgical procedures (D9215) provided on July 6, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that you were advised on the date of 
service that you did not have dental coverage. You say that a plan representative advised you would receive 
reimbursement of up to $500. The Plan denied your request. The Plan says local anesthesia in conjunction with 
operative or surgical procedures is not listed as a covered service. The Plan also says any services not listed 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, the requested items or services are not 
among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to reimburse you for the local anesthesia in 
conjunction with operative or surgical procedures (D9215) provided on July 6, 2020.