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

 
We decided that the Plan does not have to pay for the laboratory services provided on June 1, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 provided on June 1, 2021 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you were crushed in a press when you were 
younger, and the orthotics were prescribed for your back. 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 pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on April 12, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the services are medically necessary. 
The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on April 12, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) 
you received at an outpatient hospital facility on August 4, 2021. 
 
You asked the Plan to waive the copayment for the TTE. You say that you were seen in the cardiology clinic to 
a monitor was put on you.  You stated that the tape used to keep the monitor attached caused your lip to swell, 
so you had to take it off.  You don't think you should have to pay this copayment. The Plan denied your 
request. The Plan says you were charged this copayment 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 $100 
copayment for diagnostic procedures and tests at an outpatient hospital.  
 
You have been asked to pay a $100 copayment for the TTE. The TTE falls within the diagnostic procedures and tests at an outpatient hospital benefit category. This copayment applies regardless of the success of the test. 
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 transthoracic echocardiography (TTE) you received at 
an outpatient hospital facility on August 4, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous device. 
 
You asked the Plan to pre-approve the insertion of a Superion interspinous device. You say that the clinical 
evidence provided shows that the requested device is appropriate. You say that this device is a clinical and 
cost-effective option for the treatment of enrollees with intermittent neurogenic claudication secondary to mild 
to moderate degenerative lumbar spinal stenosis. You say that the requested treatment is medically necessary 
and appropriate for this stage of the disease progression and should be covered. The Plan denied your request. 
The Plan says there is insufficient long-term evidence to support the use of the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the insertion of a Superion interspinous 
device. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found this 
procedure is considered an experimental/investigational.  It does not have long-term efficacy studies and is not 
superior to standard therapy. Therefore, the request is deemed not medically reasonable and necessary. 
 
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 insertion of a Superion interspinous device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an overdenture (D5865). 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee has already received implants. 
You say that the enrollee needs this service to complete their treatment. You also say that the over denture is 
necessary. The Plan denied your request. The Plan says overdenture is not listed as a covered service. 
 
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 overdenture is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
overdenture (D5865).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the outpatient bone marrow procedure you 
had at an outpatient hospital facility on April 6, 2021. 
 
You asked the Plan to waive the cost sharing for the outpatient bone marrow procedure. You say that the 
provider told you that they reached out to the Plan to verify your benefit.  You said that you were told there 
would be no fee for the procedure. The Plan denied your request. The Plan says you were charged this cost 
sharing correctly.  The Plan says that they called the provider's office to find out if they called regarding your 
benefits for this procedure.  The office state that they do not call to check benefit coverage amounts for 
patients.  Instead, the provider said that they let you know that there may be a deductible and that copayments 
will be your responsibility. 
 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 $1000 
deductible for outpatient surgery. After you pay the deductible, you have a $350 copayment for outpatient 
surgery at an outpatient hospital facility. 
 
You have been asked to pay a $1000 deductible and a $350 copayment for the outpatient bone marrow 
procedure. The outpatient bone marrow procedure falls within the outpatient surgery 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 cost sharing for the outpatient bone marrow procedure you had at an 
outpatient hospital facility on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vascular surgery office visit to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the vascular surgery office visit. You say that you did not receive your 
denial until after your appointment with the out-of-network provider. The Plan denied your request. The Plan 
says the provider is out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the vascular surgery office visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound of the extremities you had 
on May 12, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this was a necessary part of the 
diagnosis of a cyst, so this claim should be paid in full. The Plan denied your request. The Plan says you were 
charged this copayment correctly.  The Plan says that because the allowed amount for this service ($50.06) is 
less than your copayment obligation, you are responsible for the full allowed 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 $110 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $110 copayment for the ultrasound. The ultrasound falls within the 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 the ultrasound of the 
extremities you had on May 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from June 12, 2021, to June 18, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you had a reaction 
to a shot given to you in the emergency room.  Because of this, you had to be admitted for several days.  You 
do not think you should have to pay the inpatient copayment. The Plan denied your request. The Plan says you 
were charged this copayment 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 $325 
copayment per day for days 1-5 per admission for inpatient hospital services.  
 
Records show that you were in the hospital for 6 days. You were charged a $325 copayment per day for each of the first 5 days.  This totals $1625, but the Plan is only charging you $1300. 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 inpatient hospital services you received from June 12, 2021, to June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) machine rental from January 28, 2021, through April 28, 2021. 
 
You asked the Plan to waive the coinsurance for the CPAP machine rental. You say that your rental charges 
should have ended in May 2020. You say you owned the machine at that point. 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 durable medical equipment. Your contract also clearly says that you will not own DME 
equipment no matter how many copayments you make.  
 
You have been asked to pay 20% of the allowed amount for the CPAP machine rental.  
 
Date of Service Allowed Amount 20% Coinsurance 
January 28, 2021 $70.19 $14.04 
February 28, 2021 $70.19 $14.04 
March 28, 2021 $70.19 $14.04 
April 28, 2021 $70.27 $14.05 
 
The CPAP machine rental falls within the Durable medical equipment (DME) and Related 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 coinsurance for the continuous positive airway pressure 
(CPAP) machine rental from January 28, 2021, through April 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care and hospital discharge management 
provided on April 14, 2021, to April 15, 202 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent hospital care and hospital discharge management. You say that 
the services are medically necessary. The Plan denied your request. The Plan says no prior authorization was 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for subsequent hospital care and hospital discharge management 
provided on April 14, 2021, to April 15, 202 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services (CPT code(s): 99204, 99203, 99213, 
99214) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the office services. You say that the wound is exposing the enrollee to 
additional health issues if not treated. The Plan denied your request. The Plan says there are numerous in-
network providers that can render the 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services (CPT code(s): 99204, 99203, 99213, 99214) to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs you received while in 
observation at the hospital from April 10, 2021, to April 13, 2021, or waive the copayment for the observation 
stay. 
 
You asked the Plan to pay for the self-administered drugs and to waive the copayment for the observation stay. 
You say that you went to the hospital because you were having a stroke.  You stated that you were just 
supposed to stay in the hospital so that you could get a magnetic resonance imaging (MRI). You said that they 
didn?t take the MRI for three days. You feel as though you shouldn?t have to pay this bill because you didn?t 
ask to stay in the hospital. The Plan says that self-administered drugs are not covered under your medical 
benefits.  The Plan also states that you were charged the copayment for the observation room services correctly. 
 
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 you received are not among the types which are covered by 
Medicare Part B. In addition, your contract explicitly states that you pay a copayment of $50 for hospital 
observation services.  This copayment applies regardless of the reason for your visit to the hospital Therefore, 
we decided that the Plan does not have to pay for the self-administered drugs you received while in observation 
at the hospital from April 10, 2021, to April 13, 2021, and does not have to waive the copayment for the 
observation stay.  
 
Benefits for the self-administered drugs 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Technetium and Regadenoson 
materials used during the nuclear stress test you had on April 9, 2021. 
 
You asked the Plan to waive the coinsurance for the Technetium and Regadenoson materials. You say that you 
cannot do a treadmill stress test, so you must do a nuclear stress test.  You do not believe the contract is clear 
regarding your cost sharing for the injectable material used during a nuclear stress test. You do not appear to be 
disputing the copayment for the stress test itself. The Plan denied your request. The Plan says you were charged 
this coinsurance 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 20% 
coinsurance for medical supplies.  
 
Your Plan contract says that there is usually no separate charge for medical supplies routinely used in the 
course of an office visit and included in the provider's charges for that visit.  However, supplies for which an 
appropriate separate charge is made by providers (such as chemical agents used in diagnostic procedures) are 
subject to separate cost sharing.  You have been asked to pay 20% coinsurance for the Technetium and 
Regadenoson materials. The Technetium and Regadenoson materials fall within the medical 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 coinsurance for the Technetium and Regadenoson materials 
used during the nuclear stress test you had on April 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nail debridement (11721) provided on October 29, 2020. 
 
You asked the Plan to pay for the debridement service. You say that the service provided was not related to the 
enrollee's diagnosis. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the nail debridement (11721) provided on October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedure, by 
report (D5899) provided May 28, 2021. 
 
You asked the Plan to pay for the unspecified removable prosthodontic procedure. You say that the service was 
necessary. The Plan denied your request. The Plan says the claims from this date of service have been 
reprocessed however unspecified removable prosthodontic procedure is not a covered service. 
 
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 
unspecified removable prosthodontic procedure, by report (D5899) provided May 28, 2021.