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

 
We decided that the Plan does not have to pay for the medical services provided on December 13, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that you would like reconsideration because you were 
not aware you needed to tell the Plan that you moved out-of-area. The Plan denied your request. The Plan says 
you were not referred out-of-network by the Plan and these services were 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 medical services provided on December 13, 
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve the requested service. You say that you can't get in your bed at night. The Plan denied your request. The Plan says the item is not primarily medical in nature.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The rules say that a power seat elevation feature is not primarily medical in nature. 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 power seat elevation system.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for 4Kscore testing provided on January 31, 2020. 
 
You asked the Plan to pay for 4K score testing. You say that this testing is covered by Medicare and should be 
paid. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because 
this test is not covered by Medicare. 
 
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. 
 
This testing was ordered by an in-network provider. The file does not show that the plan provided notice that 
4K score testing would not be covered. This testing was not excluded from Medicare coverage for this date of 
service. Under Medicare rules, this means 4K score testing is considered approved by the plan. Therefore, we 
decided that the Plan has to pay for 4Kscore testing provided on January 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87088, 87086, 87077, 87186) 
provided on March 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON laboratory services. You say that this should be covered. 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 laboratory services (87088, 87086, 87077, 
87186) provided on March 14, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot, insert, removable, molded to patient model, 'ucb' type, 
berkeley shell, each (L3000) provided on April 20, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that the provider called prior to have the item and were 
told that this would only be covered if you were diabetic. You state you are not diabetic and did not know the 
benefit due to the provider stating they would take care of it. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot, insert, removable, molded to 
patient model, 'ucb' type, berkeley shell, each (L3000) provided on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit provided on December 13, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for outpatient office visit. You say that you weren't aware that you needed to notify
the Plan that you moved. You say that you needed medication refilled. The Plan denied your request. The Plan
says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer
these services.
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 outpatient office visit provided on December 13,
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 the office visit services provided on October 15, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit services provided on October 15, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five additional podiatry visits.
You asked the Plan to pre-approve the additional podiatry visits. You say that you would like reconsideration
because the member needs to be seen monthly due to their condition. The Plan denied your request. The Plan
says the member has 4 covered routine supplemental podiatry visits a year.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The Health Plan offers
supplemental routine foot care coverage. The Plan contract says that up to 4 routine podiatry visits are covered.
The services you are asking the Plan to pre-approve are routine foot care services. The record indicates that the
member has received 2 routine podiatry visits. 5 additional visits exceed the benefit limit as laid out by the
contract. Based on this information, we decided that Medicare rules for coverage of the additional podiatry
visits have not been met. Therefore, we decided that the Plan does not have to pre-approve five additional
podiatry visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transportation received on December 16, 
2019. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered service 
 
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 the services. Our reviewer says that  Our 
physician reviewer found  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for non-emergency transportation received on December 16, 2019.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the SNF stay. We decided that the Plan does not have to waive the copayment for the SNF stay.
You asked the Plan to waive the copayment for the SNF stay. You say that you cannot afford this bill. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to reduce the copayment for the SNF stay.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that you were charged for the SNF discharge day. The copayment does not apply to the discharge day.
The Plan says that you must pay a $1,602 copayment for the SNF stay. Based on the plan contract, however, you cannot be asked to pay more than a $1,424 copayment for the SNF stay. Therefore, we decided that the Plan has to reduce the copayment for the SNF stay from a $1,602 copayment to a $1,424 copayment.
We also decided that the Plan does not have to waive the copayment for the SNF stay.
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 $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 21 to 100. Therefore, we decided that the Plan does not have to waive the copayment for the SNF stay.
Dates of Service
Service
Copayment per Day
SNF Days
Number of Days
Member Liability
February 21, 2020 to February 29, 2020
SNF stay
$0
1-9
9
$0
March 1, 2020 to March 11, 2020
SNF stay
$0
10-20
11
$0
March 12, 2020 to March 20, 2020
SNF stay
$178
21-29
8
$1,424
Total
$1,424
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation billed for services provided on
January 27, 2020.
You asked the Plan to pay for the ambulance services. You say that there was no need for transport to an
emergency room. The Plan denied your request. The Plan says ambulance transportation is covered only when
you are actually transported by ambulance.
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 27, 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 ambulance transportation billed for services
provided on January 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tadalafil. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tadalafil.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on January 14, 
2020. 
 
You asked the Plan to issue reimbursement for the hearing aids. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids 
were provided by an out of network provider, without prior authorization. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case.  
 
We looked at the case file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the hearings aids were purchased from an out of 
network provider, without prior authorization. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids purchased on January 14, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after 
August 7, 2020. 
 
You asked the Plan to pre-approve SNF care. You say that if you are released you will end up back in the 
hospital or worse, so discharge is not safe at this time. The Plan denied your request. The Plan says the denial 
of authorization for continued SNF care after August 7, 2020 is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled 
Nursing Facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued Skilled Nursing Facility (SNF) care after August 7, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on February 6, 
2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the charges 
because you were told that you would owe a $0 copayment for colonoscopy screenings. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
The medical records show that you had polyps removed during a colonoscopy provided on February 6, 2020. 
Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $200 
copayment.  
 
You have been asked to pay a $200 copayment for a colonoscopy. A colonoscopy falls 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 copayment for a colonoscopy provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 24, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care (99309). You say that you would like reconsideration 
because the provider relies on the hospital staff to verify eligibility and obtain proper authorization. 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 February 24, 
2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not reasonable and necessary, and doesn't meet Medicare criteria for
coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
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 pre-approve this is medically necessary. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no
identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily
basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the periodontal maintenance (D4910) 
provided on February 24, 2020. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit under your contractual policy. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the periodontal maintenance (D4910) provided on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted procedure, dentoalveolar structures (CPT Code
41899) provided to the enrollee on March 10, 2020.
You asked the Plan to pay for the dental services. You say that the service is medically necessary. The Plan
denied your request. The Plan says this service is not covered under Medicare or the Health Plan.
Medicare generally does not cover dental services. The Plan follows the same rule.
This request is not medical in nature per CMS guidelines which limits coverage to treatment of conditions such
as tumor removal or in preparation of the jaw for cancer treatment. The services you are asking the Plan to pay
for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly
supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we
decided that the Plan does not have to pay for unlisted procedure, dentoalveolar structures (CPT Code 41899)
provided to the enrollee on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 9, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on July 9, 2019.