Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic panel rendered on July 1, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. The file does not show that the 
testing was requested for an appropriate, related diagnosis. Medicare does not cover this testing solely for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic panel rendered on 
July 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on May 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on May 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services provided on December 23, 2019. 
 
You asked the Plan to pay for the transportation services. You say that the transport to your neurologist was 
medically necessary. 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 wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the transportation services provided on December 23, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for an inpatient hospital stay 
provided by a participating provderon January 12, 2020 to January 16, 2020. 
 
You asked the Plan to waive the deductible and coinsurance for an inpatient hospital stay. You say that you 
already paid a lot for this stay. You say that you do not know why you are getting another bill. The Plan denied 
your request. The Plan says the correct deductible and coinsurance 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $300 deductible and a 10% coinsurance for inpatient hospital care.  
 
You have been asked to pay $228.47 towards your deductible and a 10% coinsurance of the allowed amount 
for an inpatient hospital stay. The total allowed amount is $4,625.06. The 10% coinsurance is $462.51 
($4,625.06 x 10% = $462.51). You have asked to pay $449.28 which is less than you 10% coinsurance. The 
total amount you are being asked to pay is $677.75 ($449.28 + $228.47 = $677.75). An inpatient hospital stay 
falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
deductible and coinsurance for an inpatient hospital stay provided by a participating provider on January 12, 
2020 to January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified dental service provided on March 10, 2020 
and March 17, 2020 by an OON provider. 
 
You asked the Plan to pay for the unspecified dental service. You say that you believed your insurance would 
reimburse you for the full amount, or at least partial amount, that you paid. The Plan denied your request. The 
Plan says this service is not a covered benefit. 
 
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, you are responsible for 100% of the 
cost for dental services received from an OON provider. Therefore, we decided that the Plan does not have to 
pay for the unspecified dental service provided on March 10, 2020 and March 17, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provide on November 22, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that the 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 the file and Medicare rules. The record shows the enrollee, complaining of not feeling well, 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 services have not been met. Therefore, we decided 
that the Plan does not have to pay for the ambulance services provide on November 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service you woke up with a 
sharp needle like pain in your face and arm. Your husband called 911 and when the responders arrived, they 
treated you and advised you that you needed to go to the hospital. You say that since it was very cold, you did 
not want your husband to drive alone to the hospital, so you decided to go with him instead of the ambulance. 
You stated that the responders helped you to your car but did not mention anything about costs. You say that 
you have received multiple bills for the ambulance services and the cost is a financial burden for you. You 
asked the Plan to reconsider their decision and provide coverage for the services. 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 January 14, 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 4, 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 May 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and post and core in addition to crown provided 
on April 7, 2020. 
 
You asked the Plan to pay for the crown and post and core in addition to crown. You say that you understand 
that you have at least 50% coverage for dental services rendered by out-of-network dental providers. The Plan 
denied your request. The Plan says these 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, 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 post and core in addition to crown provided on April 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from March 5, 2020 to May 5, 
2020. 
 
You asked the Plan to pay for the chiropractic services. You say that you were told by the provider that services 
would be covered. The Plan denied your request. The Plan says you must receive care from in-network 
providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service 
area or if the care cannot be provided with an in-network provider, which requires prior authorization from the 
plan. 
 
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 chiropractic services provided from March 5, 2020 to May 5, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a 
participating provider on December 24, 2019. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you were told that this 
facility was participating. The Plan denied your request. The Plan says the correct copayment 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 $400 
copayment for outpatient surgery/in-network/surgery services/ambulatory surgical center.  
 
You have been asked to pay $373.94 which is less than your copayment amount of $400 for a diagnostic 
colonoscopy. A diagnostic colonoscopy falls within the outpatient surgery/in-network/surgery 
services/ambulatory surgical center 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 
diagnostic colonoscopy provided by a participating provider on December 24, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the colonoscopy, with lesion removal 
(45385) provided on April 7, 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 10% 
coinsurance for Medicare-covered surgery or services at an outpatient hospital or ambulatory surgical center. 
 
You have been asked to pay $28.72 ($287.22 Plan allowed amount x 10% coinsurance) for the Medicare-
covered surgery provided at an ambulatory surgical center. 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 colonoscopy, with lesion removal (45385) provided on April 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist hand finger orthosis provided on March 16, 2020. 
 
You asked the Plan to pay for the wrist hand finger orthosis. You say that this orthosis was for the left wrist and 
the last orthosis was for the right wrist. The Plan denied your request. The Plan says the you received a left 
wrist hand finger orthosis from the same provider on November 12, 2018. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you had a wrist hand finger orthosis at the time the new wrist hand finger orthosis was 
received. The new wrist hand finger orthosis serves the same purpose as the wrist hand finger orthosis received 
on November 12, 2018. This orthosis is still within the 5-year RUL and the documentation submitted does not 
show that the orthosis is irreparably worn, irreparably damaged, or that the you had a change in medical 
condition to warrant the wrist hand finger orthosis at issue. Therefore, we decided that the Plan does not have 
to pay for the wrist hand finger orthosis provided on March 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the computed tomography scan of the 
thorax (71250) and the computed tomography scan of the abdomen and pelvis (74176) provided on March 20, 
2020. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services 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 $100 
copayment for each Medicare-covered radiological diagnostic service performed in a physician?s office or at a 
free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay $200 ($100 copayment x 2 scans) for the Medicare-covered radiological 
diagnostic services provided. 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 copayments for the computed tomography 
scan of the thorax (71250) and the computed tomography scan of the abdomen and pelvis (74176) provided on 
March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97814, 97813) provided on March 16, 
2020 to March 23, 2020. 
 
You asked the Plan to pay for acupuncture services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, these services were not used to treat chronic lower 
back pain. Therefore, we decided that the Plan does not have to pay for acupuncture services (97814, 97813) 
provided on March 16, 2020 to March 23, 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 21, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care provided on January 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from October 29, 2019 to 
December 16, 2019. 
 
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 chiropractic services provided from October 29, 2019 to 
December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for a duplex scan provided on March 16, 
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 
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 for a duplex scan provided on March 16, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on September 19, 2019. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says the 
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the plan. 
 
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 outpatient hospital services provided on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on March 13, 
2020. 
 
You asked the Plan to pay for a pneumatic compression device (E0676). You say that the a pneumatic 
compression device was used during the enrollee's surgery at the request of the physician. The Plan denied your 
request. The Plan says a pneumatic compression device is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device provided on March 13, 2020.