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

 
We decided that the Plan does not have to pay for the outpatient office visit provided December 3, 2018. 
 
You asked the Plan to pay for the office visit. You say that your coverage was terminated July 
1, 2018. Please read the enclosed letter and have the claims department review all recent and past medical 
claims that have been denied. The Plan denied your request. The Plan says an explanation of benefits is needed 
before this claim can be considered. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has a different insurer as primary. As the secondary insurer, the Plan cannot be held responsible for the office visit 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for the outpatient office visit provided December 3, 2018.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on August 20, 2019. 
 
You asked the Plan to pay for the initial nursing facility care. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
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 initial nursing facility care provided on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction and surgical extraction provided on 
April 1, 2020. 
 
You asked the Plan to pay for the simple extraction and surgical extraction. You say that you are on a very 
limited income. You also say that you need more work done and also need help paying for these services. The 
Plan denied your request. The Plan says there is a waiting period prior to the availability of your dental 
benefits. The Plan also says that the waiting period is not able to be waived without evidence of creditable 
coverage and certain services you receive during the waiting period 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, there is a waiting period prior to the 
availability of your dental benefits. The contract states that this waiting period can be partially or completely 
waived if you have had past dental coverage. The record shows that you told the Plan that you did not have any 
past creditable dental coverage. Therefore, we decided that the Plan does not have to pay for the simple 
extraction and surgical extraction provided on April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 24, 2020.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says services from non-participating providers are not covered under your plan unless they are authorized by the Plan before the services are provided.

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 subsequent nursing facility care provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram provided on April 25, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for an OON electrocardiogram. You say that you were told this was authorized by 
the facility. The Plan denied your request. The Plan says this was not authorized. 
 
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 electrocardiogram provided on April 25, 2020 
by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on March 11, 2020. 
 
You asked the Plan to pay for nursing facility care. You say that the claim was billed with GV modifier stating 
not related to hospice care. You say that the claim should be reprocessed. The Plan denied your request. The 
Plan says Original Medicare is responsible for payment. 
 
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 nursing facility care provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the posterior resin-based composite of two surfaces, posterior 
resin-based composite of three surfaces, crown, core buildup, including any pins when required, mandibular 
partial denture, maxillary partial denture, and two additions of clasps to an existing partial denture provided on 
August 22, 2019. 
 
You asked the Plan to pay for the dental services.. You say that these services were necessary. You also say 
that you were of the opinion, and were assured that you would be reimbursed by your insurance company. The 
Plan denied your request. The Plan says these services are not covered benefits 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 
posterior resin-based composite of two surfaces, posterior resin-based composite of three surfaces, crown, core 
buildup, including any pins when required, mandibular partial denture, maxillary partial denture, and two 
additions of clasps to an existing partial denture provided on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services (99342, 11721) provided on March 12, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON podiatry services. You say that the enrollee said he was covered under 
Medicare. The Plan denied your request. The Plan says this was not authorized. 
 
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 podiatry services (99342, 11721) provided on 
March 12, 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 deductible and copayment the cardiovascular monitoring 
services (93229) provided January 1, 2020. 
 
You asked the Plan to waive the deductible and copayment the cardiovascular monitoring services. You say 
that the service date was incorrect and should have been 12/31/2019. You believe that you met your annual 
deductible for 2019 and this erroneous service date would increase your medical expense by $300. The Plan 
denied your request. The Plan says the cost share was applied correctly per the 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 there is a $300 
deductible and that you must pay $20 copayment for diagnostic non-radiological services. for Outpatient 
diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $320 for the cardiovascular monitoring services. The cardiovascular monitoring 
services falls within the Outpatient diagnostic tests and therapeutic services and 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 deductible and copayment the cardiovascular monitoring services (93229) 
provided January 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Laminectomy for implantation of 
neurostimulator electrodes (63655) provided January 22, 2020 to January 29, 2020. 
 
You asked the Plan to waive the coinsurance for the outpatient surgery services. You say that the surgery 
required you to stay in the hospital overnight and it was charged as outpatient surgery. You believe that should 
have been charged as an in-patient as your doctor required you to stay. The Plan denied your request. The Plan 
says this claim processed with the correct coinsurance per the 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 20% 
coinsurance for surgery performed at an outpatient hospital facility.  
 
You have been asked to pay $3,611.63 for the outpatient surgery services. The provider billed $18,058.15. 
(20% x $18,058.15 = $3,611.63). The outpatient surgery services fall within the Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers 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 Laminectomy for implantation of neurostimulator electrodes 
(63655) provided January 22, 2020 to January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray provided on February 5, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that the office personnel advised that your 
insurance covered these x-rays every 5 years. You also say that you are on a fixed income. The Plan denied 
your request. The Plan says a full mouth series of x-rays is not a covered benefit under your 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. The Plan only covers bitewing x-rays. Therefore, we decided that the 
Plan does not have to pay for the panoramic x-ray provided on February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on September 26, 2019. 
 
You asked the Plan to pay for drug tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the 
documentation submitted does not include a valid physician order, lab requisition, or medical records stating 
exactly which tests were to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 22, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services (99307). You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says prior authorization is required and 
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 the medical services provided on November 22, 
2019 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 crown and extraction provided on May 12, 2020. 
 
You asked the Plan to pay for the crown and extraction. You say that the dentist office said these services 
would be covered by your Plan, and your copay would be $142. You also say that the list of changes in 
coverage was unclear. The Plan denied your request. The Plan says these services are not covered benefits. 
 
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 crown 
and extraction provided on May 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 31, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services (90832). You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says prior authorization was not 
obtained as required under the Plan benefits. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on March 31, 2020 
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan 
provided on December 16, 2019. 
 
You asked the Plan to waive the copayment for CT scan. You say that this amount should not be billed for a 
CT scan. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $225 
copayment for CT scan provided in an outpatient hospital.  
 
You have been asked to pay the allowed amount of $224.33, which is less than the $225 copayment for CT 
scan. CT scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for a Computed Tomography (CT) scan provided 
on December 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that insurance paid for this the last time. The 
Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 25, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided  on March 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 18, 2017. 
 
You asked the Plan to pay for ambulance services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our physician reviewer 
found there was no need for ambulance transport of this patient to the emergency department (ED). The 
enrollee did not voice a complaint and they had stable vital signs and nothing to suggest that ambulance 
transport was indicated or that there was any emergency. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does 
not have to pay for ambulance services provided on April 18, 2017.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on March 22, 2020. 
 
You asked the Plan to pay for wound care services. You say that there is an ulcer on your tailbone with bone 
exposure. You say that you needed wound treatment. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
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 wound care services provided on March 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on July 2, 2019. 
 
You asked the Plan to pay for drug tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to 
be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on July 2, 2019.