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

We decided that the Plan does not have to pay for the 2D oral/facial photographic image provided on May 27, 2020.
You asked the Plan to pay for the 2D oral/facial photographic image. You say that you didn't know what kind of x-ray the dentist provided. You say that the x-ray cost more than insurance covered. The Plan denied your request. The Plan says the 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, 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 2D oral/facial photographic image provided on May 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a grab bar and a shower chair provided on January 2, 2020. 
 
You asked the Plan to pay for a grab bar and a shower chair. You say that you fell and broke your shoulder. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars and shower chairs are not 
covered because they are not primarily medical in nature.  
 
While a grab bar and shower chair may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of this item. Therefore, we decided that the Plan does not have to pay for a grab bar and a shower 
chair provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the services provided on February 5, 2020, by an out-
of-network provider. 
 
You asked the Plan to reimburse for the services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says the services for Micro nutrient Blood Panel and 
Comprehensive Digestive Stool Test Parasitology because the Plan requested an itemized billing statement 
with the proper codes and billed amount for each code and it has not been received. 
 
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 services for Micro Nutrient Blood Panel and Comprehensive Digestive Stool Test Parasitology because the 
Plan requested an itemized billing statement with the proper codes and billed amount for each code and it has 
not been received. Furthermore, since the plan did provide coverage for CPT Code 99201, CPT Code 99214, 
CPT Code 84999 and CPT Code 83520 you are still responsible for a cost-share. At the time of services 
rendered you had not met your $1500 deductible; therefore, you have been asked to pay $1054.74 for the 
services to apply to your deductible. 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 reimburse for the services provided on 
February 5, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse more for the interim denture (D5811) and the extraction 
(D7140) provided on September 4, 2019. 
 
You asked the Plan to reimburse more for the dental services. You say that this is the first time you have had a 
tooth pulled in 10 years. You also say you are not sure why the payment for the denture was so low. The Plan 
denied your request. The Plan says there is a maximum allowance of $500 per year for preventive and 
comprehensive dental services that are not covered by Medicare. The Plan says that the maximum allowance 
was reached while processing this claim. The Plan also says you are responsible for any amount above the 
dental coverage limit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum allowance of $500 for 
dental service has been exceeded. The record shows that the Plan paid $411.63 for services you received on 
January 17, 2019. After those services were paid, only $88.37 was left of the maximum allowance, thus that 
was all that could be applied to the services you received on September 4, 2019. Additionally, the Evidence of 
Coverage clearly states that you are responsible for any amount above the dental coverage limit. Therefore, we 
decided that the Plan does not have to reimburse more for the interim denture (D5811) and the extraction 
(D7140) provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 26, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for practitioner visit. You say that it was your understanding that when a provider is 
called to see a patient during their nursing home stay the services would be covered, and the facility would be 
responsible for obtaining authorization. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because this provider is out-of-network with the Plan and authorization 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 September 26, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 27, 2020. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 physician's services provided on April 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient hospital care provided from January 11, 2020 to January 13, 2020.You asked the Plan to pay forthe inpatient hospital care. You say that the inpatient hospital care provided from January 11, 2020 to January 13, 2020 was medically necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to an in-network provider on 1/11/20.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 the inpatient hospital care. Our reviewer says that the inpatient hospital care provided from January 11, 2020 to January 13, 2020 was not medically necessary. Our physician reviewer found the review has determined that by 1/11/2020 at 10:08 a.m., the enrollee was stable for ambulance transport with monitoring to a Plan facility because she was off BiPAP, sating well on nasal cannula and responding well to treatment. The post-stabilization care services from January 11, 2020 to January 13, 2020 were not medically necessary or reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe inpatient hospital care provided from January 11, 2020 to January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee. 
 
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 the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network services 
provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on March 2, 2020. 
 
You asked the Plan to pay for the outpatient hospital 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 
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 March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from June 
14, 2020, through June 19, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The 
Plan says authorization was not obtained by the provider or the 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 a behavioral health inpatient admission provided from June 14, 
2020, through June 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forGuardant 360 testing provided on December 31, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says The Plan says this is an administrative determination for coding and is not based on clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the claim is missing the main code and identifier required by Medicare. Based on this information, we decided that Medicarerules for coverage of this claim have not been met.Therefore, we decided that the Plan does not have to pay forGuardant 360 testing provided on December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided on February 10, 
2020. 
 
You asked the Plan to pay for the pulp vitality tests. You say that you had a broken tooth, and were told you 
needed a crown because of the large break that had decay hidden under it. 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 pulp 
vitality tests (D0460) provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 28, 2020. 
 
You asked the Plan to pay for the physician's 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 
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 January 28, 2020.
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 May 22, 2020. 
 
You asked the Plan to waive the copayment for CT scan. You say that you were told the benefit amount for this 
was $275 but the provider only charged $239, and this does not make sense. 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 $275 
copayment for CT scan performed by a provider other than your PCP.  
 
You have been asked to pay the allowed amount of $239.09, which is less than the $275 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 May 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for 
edema. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for an office visit provided on June 15, 2020. 
 
You asked the Plan to reduce the copayment for office visit. You say that this was an urgent care visit, so your 
copayment should only be $15. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay $5 copayment for an office visit with a non-specialist health 
care professional. This visit was provided at a walk-in clinic and not an urgent care facility. The rendering 
provider is a nurse practitioner of family medicine, which is not a specialist physician, therefore the other 
health care professional copayment applies to this claim and not the specialist copayment. 
 
The Plan says you must pay $50 copayment for office visit. Based on the Plan contract, however, you cannot 
be asked to pay more than $5 copayment for office visit. Therefore, we decided that the Plan has to reduce the 
copayment for an office visit provided on June 15, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 18, 2020. 
 
You asked the Plan to pay for the laboratory 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 
laboratory 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 laboratory services provided on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glycosylated hemoglobin test (83036) provided on June 
19, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for glycosylated hemoglobin test. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says pre 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 glycosylated hemoglobin test (83036) 
provided on June 19, 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 CT scans provided by a participating
provider on May 8, 2020.
You asked the Plan to waive the copayment for CT scans. You say that you think that you are being charged
too much money. 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 $110
copayment for outpatient diagnostic/in-network/radiological diagnostic services.
You have been asked to pay a total amount of $414.95 ($110 + $110 + $110 + $84.95 = $414.95) for CT scans.
CT scans falls within the outpatient diagnostic/in-network/radiological diagnostic 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 CT scans provided by a participating provider on May 8,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the external counterpulsation per treatment 
session (G0166) provided February 3, 2020 to March 18, 2020. 
 
You asked the Plan to waive the copayment for the external counterpulsation sessions. You say that you had 
the same procedure done in 2012 with another insurance plan and had no copayment and feel that there should 
not be a copayment this time. The Plan denied your request. The Plan says the claims have processed correctly 
per the Evidence of Coverage. 
 
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 $40 
copayment for each specialist's office visit for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $40 for each external counterpulsation session. The external counterpulsation 
sessions 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 the external counterpulsation per treatment session (G0166) 
provided February 3, 2020 to March 18, 2020.