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

 
We decided that the Plan has to pay for the bitewing- four radiographic images provided on March 18, 2020. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you were informed the x-rays were necessary. 
You say that your plan states x-rays are covered once every two years. The Plan denied your request. The Plan 
says the service is not a covered benefit. 
 
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 provided bitewing x-rays by a network provider. The contract says that x-rays are covered. Although 
the contract does only list one and two view bitewing x-rays as covered, we find that this would not be 
considered adequate notice that the bitewing x-ray the network provider gave you (with four views) would not 
be covered. There is no evidence that the network provider gave notice that the x-ray provided would not be 
covered or that you were informed how many views were to be provided prior to the exam being completed. 
Under Medicare rules, this means the bitewing x-ray is considered approved by the Plan. Therefore, we decided 
that the Plan has to pay for the bitewing- four radiographic images provided on March 18, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine you received on December 5, 2019. 
 
You asked the Plan to pay for the vaccine. You say that the vaccine was necessary. The Plan denied your 
request. The Plan says this is not covered under your Part B plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on December 5, 
2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transport (A0428, A0425) 
provided March 17, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be 
waived. 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 $350 
copayment for Ambulance Services.  
 
You have been asked to pay a $350 copayment for the ambulance transport. The ambulance transport falls 
within the Ambulance 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 
an ambulance transport (A0428, A0425) provided March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on February 15, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says that 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
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 a domiciliary, rest home visit provided on February 15, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit (99348) provided on August 14, 2019. 
 
You asked the Plan to pay for a home visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says the home visit was provided by an RN. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. A home visit cannot be billed by a physician 
unless the physician was actually present in the beneficiary's home. 
 
We find that CPT code 99348 is not supported in the medical record. Specifically, the records do not support 
that the billing physician was present in the enrollee's home. The records indicate that the visit in question was 
a skilled nursing visit performed by a registered nurse. Based on this information, we decided that Medicare 
rules for coverage of a home visit have not been met. Therefore, we decided that the Plan does not have to pay 
for a home visit (99348) provided on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayments charged for specialist office visits 
from January 29, 2020 to March 12, 2020. 
 
You asked the Plan to waive or reduce these copayments. You say that you do not believe these copayments 
are correct and you were dissatisfied with the treatment. The Plan denied your request. The Plan says these 
copayments were charged based on the services provided and the Plan contract agreement. The Plan states your 
concerns or grievance regarding the unhappiness with the services rendered are being addressed separately.  
 
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 $35 
copayment for each specialist office visit. 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 or reduce the copayments charged for 
specialist office visits from January 29, 2020 to March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the dialysis services rendered from 
January 7, 2020 to February 28, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you were not expecting the 
financial burden. The Plan denied your request. The Plan says the coinsurance was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare-covered dialysis services within the service area when ordered by your PCP.  
 
Review of the file shows that you received dialysis services from January 7, 2020 to February 28, 2020. You 
have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered 
dialysis services within the service area when ordered by your PCP 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 dialysis services rendered from January 7, 2020 to February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B injections provided from 
January 6, 2020 to March 3, 2020. 
 
You asked the Plan to waive the coinsurance for the Part B injections. You say that you should only be 
responsible for a $55 copayment. You say the shots for your osteoporosis are too expensive. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing 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 Medicare-covered Part B chemotherapy drugs and other Part B drugs.  
 
You have been asked to pay a total of $1,253.86 for the Part B injections. The Part B injections fall within the 
"Medicare Part B prescription drug" benefit category. The record shows you were charged for the Part B 
injections. See chart below. 
 
Dates of Service Service Allowed Amount Coinsurance Member Liability 
January 6, 2019 Part B injection $1,908.06 20% $381.61 
February 6, 2020 Part B injection $1,908.06 20% $381.61 
March 3, 2020 Part B injection $2,453.22 20% $490.64 
Total    $1,253.86 
 
 
  
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 Part B injections provided from January 6, 2020 to 
March 3, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for CPT code 99283 provided on March 1, 2020. 
 
You asked the Plan to pay for CPT code 99283. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says that payment is not allowed for this service because it 
is not appropriate for the diagnosis billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided any documentation showing that CPT 
code 99283 is not payable when billed with diagnosis code Z01.30. We find that the Plan has not substantiated 
their reasoning for denial based on Medicare criteria. Therefore, we decided that the Plan has to pay for CPT 
code 99283 provided on March 1, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on February 6, 2020.

You asked the Plan to pay for the comprehensive periodontal evaluation. You say that providers you know don't accept your insurance. You say that you don't have a choice to get reimbursed for your dental services. The Plan denied your request. The Plan says out-of-network dental 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, 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 comprehensive periodontal evaluation provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bariatric surgery evaluation. 
 
You asked the Plan to pre-approve the requested services. You say that you are looking for post-surgery visits. 
The Plan denied your request. The Plan says the documentation received does not show the criteria have been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees 
who meet coverage criteria.   
 
We looked at the file, and Medicare rules. The documentation shows the enrollee has a BMI of 33. As the 
enrollee would not meet the criteria to have bariatric surgery covered by Medicare or the health plan, an 
evaluation to discuss this type of surgery also would not be covered by the Plan. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a bariatric surgery evaluation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient admission provided from February 20, 2020 to 
February 26, 2020. 
 
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says all inpatient 
services 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 
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 an inpatient admission provided from February 20, 2020 to 
February 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on February 24, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 diagnostic radiology services provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 13, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
Plan requires utilization of network providers when possible and available and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visit provided by an out-of-
network provider on December 15, 2019. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received urgently needed services with an out-of-network provider on the date 
of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with 
the Plan. 
 
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 urgently needed visit in a non-contracted Urgent Care Center or walk-in clinic in the 
United States.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received urgently needed 
services with an out-of-network provider on December 15, 2019. You have been asked to pay a $40 copayment 
for the urgent care visit. The urgent care visit falls within the Urgently needed 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 reduce the copayment for the urgent care visit provided by an out-of-network 
provider on December 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance provided on February 27, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that your dental brochure states that you 
are to be reimbursed a maximum of up to $100.00 for one non-Medicare covered oral exam and cleaning for 
2020. You also say that you were not aware that there were different types of cleanings. 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 
periodontal maintenance provided on February 27, 2020.  
 
Your complaint about being misled by the Plan?s literature 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 4, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
there is no valid referral for this service. 
 
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 December 4, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on March 21, 2020 to April 20, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with 
these services. 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 $120 
copayment for emergency care/in-network/emergency services.  
 
You have been asked to pay a $120 copayment for an emergency room visit. The total amount you are being 
asked to pay is $240 ($120 x 2 ER visits = $240). An emergency room visit falls within the emergency care/in-
network/emergency 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 an 
emergency room visit provided by a participating provider on March 21, 2020 to April 20, 2020.