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

 
We decided that the Plan does not have to pay for injections provided on January 08, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for injections. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says if the enrollee needs Medicare-covered medical care and a network provider is unable to 
provide this care, the enrollee may be able to get care from an out-of-network provider. Our plan must confirm 
there is not a network provider available and contact the plan to request authorization for the enrollee to obtain 
services from an out-of-network provider. If approved, the out-of-network provider will be issued an 
authorization to provide the service (s). 
 
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 injections provided on January 08, 2022, 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 magnetic resonance imaging (MRI) on July 
29, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $75 
copayment for Advanced Imaging Services when provided in a physicians office. Covered services include but 
are not limited to other outpatient diagnostic tests including Advanced Imaging Services (e.g., Magnetic 
Resonance Imaging [MRI], Magnetic Resonance Angiography [MRA], Positron Emission Tomography [PET], 
Computed Tomography [CT] scans and Nuclear Medicine Testing). 
 
 
 You have been asked to pay a $75 copayment for MRI. This item/service 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 magnetic resonance imaging (MRI) on July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided from 
January 28, 2022, to May 13, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you feel you should not be 
charged a copayment because you say you did not see a specialist. The Plan denied your request. The Plan says 
the cost sharing will be applied according to the Plan contract. 
 
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 $25 
copayment per visit for in-network physician/Practitioner services/ specialist.  
 
You have been asked to pay a $25 copayment per visit for specialist office visit. The total amount you are 
being asked to pay is $125 ($25 x 5 visits = $125). 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 
specialist office visit provided from January 28, 2022, to May 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. All medically necessary is being provided in the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 05, 2022, to July 06, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of our plan's network) will not be covered. 
 
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 home health services provided on May 05, 2022, 
to July 06, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pathology tissue exam provided on April 29, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the tissue exam. You say that the facility is an independent lab and should not 
require separate authorization. The Plan denied your request. The Plan says a valid referral/authorization was 
not obtained prior to services being rendered. 
 
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 a pathology tissue exam provided on April 29, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SSBCI Program 
 
You asked the Plan to pre-approve SSBCI program. You say that due to your medical condition, you need your 
Grocery benefit. The Plan denied your request. The Plan says you do not meet the requirements for the SSBCI 
program. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI Program have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve SSBCI Program
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for advanced imaging services provided on 
June 13, 2022. 
 
You asked the Plan to waive the copayment for advanced imaging services. You say that you are appealing the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged 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 $150 
copayment for outpatient diagnostic tests/advanced imaging services.  
 
You have been asked to pay a $150 copayment for advanced imaging services. This item/service falls within 
the outpatient diagnostic tests/advanced imaging 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 advanced imaging services provided on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia provided on February 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for anesthesia. You say that this service was needed based on medical necessity and 
we are asking the plan to reconsider payment. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 anesthesia provided on February 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compressor provided on April 20, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a pneumatic compressor. You say that this should be covered and is medically 
necessary. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 a pneumatic compressor provided on April 20, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office Visit (with in-office procedure performed) provided 
on April 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office Visit (with in-office procedure performed). You say that this should be 
covered. The Plan denied your request. The Plan says there was no preauthorization by a primary care provider 
(this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 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 an office Visit (with in-office procedure 
performed) provided on April 12, 2022, 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 a specialist office visit provided on August 
4, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you are appealing the cost 
share The Plan denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for in-network physician/Practitioner services/specialist.  
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the in-
network physician/Practitioner services/specialist 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 specialist office visit provided on August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided from April 
29, 2022, to July 26, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that you feel it is unfair for the 
providers office to be billing differently causing a higher copay. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $35 
copayment per visit for physician/practitioner services/specialist office visit.  
 
You have been asked to pay a $35 copayment per visit for specialist office visits. The total allowed amount for 
office visits is $140 ($35 x 4visits = $140). However, you are only being charged $84.47 which is less than the 
required amount. 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 specialist office visits provided 
from April 29, 2022, to July 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing or skilled therapy needs.  
Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. 
 
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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral imaging 
(D0220), and a re-cemented crown (D2920), provided by a participating provider on June 27, 2022. 
 
You asked the Plan to pay for a limited oral evaluation, intraoral imaging, and a re-cemented crown. You say 
that this was an emergency dental situation. The Plan denied your request. The Plan says the rendered dental 
work 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 Plans 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 a limited 
oral evaluation (D0140), intraoral imaging (D0220), and a re-cemented crown (D2920), provided by a 
participating provider on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 
33, 45, 52, 58, nonavalent (HPV) (90651) provided February 15, 2022. 
 
You asked the Plan to pay for the HPV vaccine. You say that you are requesting an expedited appeal and 
approval since this claim process has continued since early March with no resolution. The Plan denied your 
request. The Plan says HPV is not a covered vaccine under Medicare Part B. The clinical value and 
effectiveness of HPV Vaccine in the setting of prevention of HPV infection in people over 45 years of age have 
not been demonstrated in the peer-reviewed literature. 
 In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the HPV vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the HPV vaccine. 
Therefore, we decided that the Plan does not have to pay for the Human Papillomavirus vaccine types 6, 11, 16, 
18, 31, 33, 45, 52, 58, nonavalent (HPV) (90651) provided February 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA). 
 You asked the Plan to pre-approve PVA. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered when certain criteria are met. 
 
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 PVA. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the imaging studies show bone retropulsion 
into the spinal canal which is a contraindication to kyphoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve percutaneous vertebral augmentation (PVA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the culture services coded 87150 and two units of infectious 
agent detection by nucleic acid coded 87801 provided on May 24, 2022. 
 
You asked the Plan to pay for the culture services and infectious agent detection by nucleic acid. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services rendered are not 
supported. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Medicare rules also say that providers must report the 
actual number of units provided for each procedure code. 
 
The culture test at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. The documentation only supports one unit of code 87801. This means 
the remaining two units are not supported. Therefore, we decided that the Plan does not have to pay for the 
culture services coded 87150 and two units of infectious agent detection by nucleic acid coded 87801 provided 
on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a topical application of fluoride varnish (D1206) provided on 
July 11, 2022. 
 
You asked the Plan to pay for a topical application of fluoride varnish (D1206). You say that you switched to 
this Plan for dental. You also say that you will have to go back to your old plan if your current plan will not pay 
for this service. The Plan denied your request. The Plan says the service rendered is not covered. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a topical 
application of fluoride varnish (D1206) provided on July 11, 2022.