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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a cochlear implant provided on April 5, 
2022. 
 
You asked the Plan to waive the coinsurance for a cochlear implant. You say that you cannot afford this 
coinsurance amount, you were unaware of the cost when you had this done. The Plan denied your request. The 
Plan says the coinsurance applied was 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 a 20% 
coinsurance for durable medical equipment (DME) and related supplies. Each piece of the implant: ($8899.74 x 
20% = $1,779.95) + ($332.78 x 20% = $66.56) + ($465.33 x 20% = $93.07) + ($108.39 x 20% = $21.68) = 
$1,961.26. 
 
You have been asked to pay a $1,961.26 coinsurance for a cochlear implant. a cochlear implant 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 a cochlear implant provided on April 5, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 21, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. 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 a $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient clinic visit provided on 
December 20, 2021. 
 
You asked the Plan to waive the copayment for an outpatient clinic visit. You say that you were not told by the 
provider a copayment was due at time of visit. You say that you disagree with the way the visit is being billed 
as an "outpatient hospital stay" and you were unaware of how expensive the visits were. The Plan denied your 
request. The Plan says the copayment applied 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 a $200 
copayment for all other outpatient services not provided in an ambulatory surgical center.  
 You have been asked to pay a $200 copayment for an outpatient clinic visit. An outpatient clinic visit 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 an outpatient clinic 
visit provided on December 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 25, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. 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 a $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient clinic visit provided on 
January 24, 2022. 
 
You asked the Plan to waive the copayment for an outpatient clinic visit. You say that you were not told by the 
provider a copayment was due at time of visit. You say that you disagree with the way the visit is being billed 
as an "outpatient hospital stay" and you were unaware of how expensive the visits were. The Plan denied your 
request. The Plan says the copayment applied 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 a $125 
copayment for all other outpatient services not provided in an ambulatory surgical center. 
 You have been asked to pay a $110.84 copayment for an outpatient clinic visit, which is less than the $125 
copayment. An outpatient clinic visit 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 an outpatient clinic visit provided on January 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested continuation of SNF care is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF 
care. 
 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 
enrollee does not meet criteria for continued SNF care. Our physician reviewer found the enrollee is with 
obstructive uropathy, congestive heart failure, obstructive sleep apnea, urinary tract infection, and dementia. 
From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. His 
lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy and occupational 
therapy. The enrollee was at a minimal to contact guard assist with functional mobility including gait to 200 
feet. The enrollee required varying assist with activities of daily living.  
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
March 16, 2022. 
 
You asked the Plan to waive the copayment for the PT services. You say that you were not aware that you 
would owe $30 for each visit. 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 a $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for the PT services. The PT services fall within the Outpatient 
Rehabilitation 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 physical 
therapy (PT) services provided on March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient level of care for the approved right total 
shoulder arthroplasty. 
 
You asked the Plan to pre-approve an inpatient level of care for the approved right total shoulder arthroplasty. 
You say that the requested inpatient level of care for the approved right total shoulder arthroplasty is medically 
necessary. The Plan denied your request. The Plan says the requested inpatient level of care for the approved 
right total shoulder arthroplasty is not medically necessary. 
 
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 an inpatient level of care for the 
approved right total shoulder arthroplasty. Our reviewer says that the requested inpatient level of care for the 
approved right total shoulder arthroplasty is not medically necessary. Our physician reviewer found the 
enrollee is medically stable with a past medical history of coronary artery disease, chronic atrial fibrillation, 
chronic obstructive pulmonary disease, hypertension, long term use of anticoagulant, and prediabetes. The 
planned procedure listed under CPT codes 23472 & 23473 is NOT LISTED on the CMS Inpatient Only List. 
The procedure is currently approved as an ambulatory procedure. The review has determined that the requested 
inpatient level of care is not medically reasonable or necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient level of care for the approved right total shoulder arthroplasty have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient level of care for 
the approved right total shoulder arthroplasty.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by code 98942. We decided that the Plan does 
not have to pay for the services described by codes 99204 and 97140.  
 
You asked the Plan to pay for the services provided by the chiropractor. You say that you had a referral for 
these services that expired. You believe these visits should be covered since your provider did refer you. The 
Plan says that 97140 is only covered by Medicare for lymphedema. The Plan did not address the other two 
codes at issue.  
We decided that the Plan has to pay for the services described by code 98942.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 
 
The services described by 98942 are manual manipulation of the spine. The Plan has not indicated any reason 
that this should not be paid. Therefore, we decided that the Plan has to pay for the services described by code 
98942.  
 
We also decided that the Plan does not have to pay for the services described by codes 99204 and 97140. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 
 
The other billed services are not covered by Medicare when provided by a chiropractor. Therefore, we decided 
that the Plan does not have to pay for the services described by codes 99204 and 97140. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an intraoral full mouth x-ray series (D0210) 
provided on May 12, 2022. 
 
You asked the Plan to waive the deductible for x-rays. You say that the x-rays should be covered. 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 a $100 
deductible for Class 2 Basic Services, including intraoral full mouth x-rays. The item or service you asked the 
Plan to waive the deductible for falls within the Dental Services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $100 
deductible which applies to intraoral x-rays. This cost sharing is a contractual obligation that had not been met 
at the time an intraoral full mouth x-ray series was received on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
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. 
 
The record shows the enrollee received the requested dental services from an out-of-network provider. Though 
the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered 
under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for dental services provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on April 26, 2022. 
 
You asked the Plan to pay more for dental services. You say that you would like to request reconsideration of 
the dental services provided. The Plan denied your request. The Plan says your medical plan has an allowance 
for certain dental services. This payment is from that amount. 
 
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 Plan is only obligated to reimburse 
based on the allowed amount for each service billed on a claim. The Plan reimbursed the full billed amount of 
this claim and additional reimbursement is not required. Therefore, we decided that the Plan does not have to 
pay more for the dental services provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210), 
periodontal maintenance (D4910), and topical application of fluoride (D1206) provided from March 24, 2021, 
through March 31, 2021. 
 
You asked the Plan to pay for the dental services. You say that you submitted the claim on November 29, 2021. 
The Plan denied your request. The Plan says they did not receive the claim until April 4, 2022. Part C claims 
must be mailed within 12 months of the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until April 4, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for a complete series of radiographic images (D0210), periodontal maintenance 
(D4910), and topical application of fluoride (D1206) provided from March 24, 2021, through March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling and root planing, four or more teeth per quadrant, 
(D4341 x 3), and scaling and root planing, one to three teeth per quadrant, (D4342) provided from May 20, 
2022, to June 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that due to the condition of your teeth, you are not 
able to receive regular cleanings. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 scaling and root planing are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for scaling 
and root planing, four or more teeth per quadrant, (D4341 x 3), and scaling and root planing, one to three teeth 
per quadrant, (D4342) provided from May 20, 2022, to June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), periapical radiographic 
images (D0220, D0230), bitewing radiographic images (D0274), teeth cleaning (D1110), topical application of 
fluoride (D1208), and a filling (D2335) provided from July 23, 2021, through July 29, 2021, by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for these services. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), periapical radiographic images (D0220, D0230), bitewing 
radiographic images (D0274), teeth cleaning (D1110), topical application of fluoride (D1208), and a filling 
(D2335) provided from July 23, 2021, through July 29, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided May 6, 
2022. 
 
You asked the Plan to pay for the eye refraction. You say that you were not aware that this would not be 
covered. The Plan denied your request. The Plan says this service is not covered when billed with a medical 
diagnosis.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The documentation show that the eye refraction was billed with a 
medical eye exam. The Plan has verified with the provider that you were seen for a diagnosis of other 
secondary cataract, bilateral. Based on this information, we decided that the Plan's rules for coverage of the eye 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the determination of 
refractive state (92015) provided May 6, 2022.