Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on July 26, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says the services provided can be obtained from an 
in-network provider. The medical records obtained do not include any mention or order for the device 
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 pneumatic compression device provided on July 
26, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core in addition to a crown (D2954) 
for tooth number 31, and a porcelain/ceramic crown (D2740) for tooth number 31 provided on July 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that at no time during your three visits to the dentist 
were you made aware that they were no longer in-network. You also say you never received any letter from the 
Plan or the provider stating these changes that happened in between the enrollee's course of treatment. 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. 
 
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. The record also shows you received the requested dental services from 
an out-of-network provider. The Plan rules also say they only cover services when received from a contracted 
provider with the Plans dental vendor. Therefore, we decided that the Plan does not have to pay for a 
prefabricated post and core in addition to a crown (D2954) for tooth number 31, and a porcelain/ceramic crown 
(D2740) for tooth number 31 provided on July 11, 2022.  
 
Your complaint about potentially not being informed of the provider no longer being in-network is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on October 27, 
2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $500 dental benefit maximum allowance for 
the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service 06/15/2022. Therefore, 
we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on October 27, 
2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 21, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of March 10, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
September 21, 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 the enrollee's condition has improved 
and would further benefit from an LTACH level of care as they still require care at the acute level. You say that 
the enrollee has had previous admissions and is high risk for readmission. You say that the enrollee's needs 
aggressive pulmonary toilet, monitoring of daily labs, glucose management and physical therapy to improve 
their strength. The Plan denied your request. The Plan says an LTACH admission is not medically necessary, 
and the enrollee can safely receive the care they need in another setting. 
 
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 enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on August 25, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. 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 $150 
copayment for copayment for Medicare-covered radiological diagnostic services, not including X-rays, 
performed in a physicians office or at a free-standing facility (such as a radiology center or medical clinic). 
Covered services include but are not limited to other outpatient diagnostic tests - Radiological diagnostic 
services, not including x-rays. The provider billed in the amount of $718 and the allowed amount is $124.42. 
This is less than the copayment amount. Therefore, results in the total cost sharing amount of $124.42. 
 
 
 You have been asked to pay a $124.42 copayment, which is less than the copayment for ultrasound. This 
item/service falls within the Outpatient diagnostic tests and therapeutic 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 ultrasound on August 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for IV therapy provided on June 14, 2022. 
 
You asked the Plan to waive the copayment for the IV therapy. You say that you never paid this amount for 
these services before. 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 $250 
copayment for surgical, IV therapy, and blood transfusion services.  
 
You have been asked to pay $184.21, which is less than the $250 copayment for the IV therapy. This 
item/service falls within the surgical, IV therapy, and blood transfusion 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 IV therapy provided on June 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on November 23, 2021. 
 
You asked the Plan to waive the copayment for ambulance. 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 $360 
copayment for each Medicare-covered trip (one-way) for ambulance. Covered ambulance services include 
fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide 
care if they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. The allowed amount is $267.75, this is less than the 
copayment amount. Therefore, results in the total cost sharing amount of $267.75. 
 
 
 
 
 You have been asked to pay a $267.75 copayment, which is less than the copayment for ambulance. This 
item/service falls within the Ambulance 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 ambulance on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the remote lab testing services provided 
on June 30, 2021. 
 
You asked the Plan to waive the cost sharing for the remote lab testing. You say that you were not notified that 
your provider was going out-of-network. 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 50% of 
the Medicare-allowed amount in all settings out-of-network for diagnostic procedures and tests.  
 
You have been asked to pay $40.85 for remote lab testing ($81.70 x .50). This item/service falls within the 
diagnostic procedures and tests 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 remote lab testing services provided on June 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on August 28, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you were not given a choice 
about this ambulance ride, you should not have to pay a 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for an ambulance ride. This item/service falls within the 
ambulance 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 an ambulance ride 
provided on August 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 16, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on February 28, 2022, to May 03, 
2022. 
 
You asked the Plan to pay for the office visits. You say that you want to see female doctors, and the network 
doctor is in a bad neighborhood. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visits provided 
on February 28, 2022, to May 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on April 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for oxygen equipment. You say that the portable oxygen tank you were using was 
too heavy for your use. The Plan denied your request. The Plan says services were rendered by a non-
participating provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 oxygen equipment provided on April 27, 2022, by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting admission into an Inpatient 
Rehabilitation Facility (IRF) for the enrollee from Acute care. The Plan denied your request. The Plan says the 
enrollee's records received do not indicate the need for an intensive therapy program with multiple visits from a 
rehabilitation doctor per week. The enrollee may safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided safely in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility care services 
provided on February 1, 2022, to February 25, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility care services. You say that you are 
disputing the share cost. 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 $188 
copayment per day for days 21 to 100 for skilled nursing facility care. You met your out-of-pocket max for the 
year, therefore the copayment is $2,861.20 instead the $4,700. 
 
You have been asked to pay $188 copayment per day for days 21 to 100 for skilled nursing facility care 
services. This item/service falls within the skilled nursing facility care 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 skilled nursing facility care services provided on February 1, 2022, 
to February 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dentures (D5120) provided on June 25, 2021 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your $1,000 dental benefit maximum for the 
requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 25, 2021. Therefore, 
we decided that the Plan does not have to pay for dentures (D5120) provided on June 25, 2021
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a determination of refractive state (92015), progressive lenses (V2781), 
polycarbonate lenses (V2784), and standard lenses (V2750) provided on September 8, 2022. 
 
You asked the Plan to pay for a determination of refractive state (92015), progressive lenses (V2781), 
polycarbonate lenses (V2784), and standard lenses (V2750). You say that you had two frames you wanted to 
have lenses replaced after surgery. The Plan denied your request. The Plan says that they do not cover this out-
of-network vision care service/material. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not supported their denial reason. The case file shows 
that the provider is contracted with the Plan. The case file also shows that the enrollee has in-network and out-
of-network coverage for eyewear following cataract surgery. The Plan has not provided medical records or 
evidence of having made reasonable attempts to obtain medical records. The Plan has not demonstrated that the 
benefit for eyewear is exhausted or that criteria for coverage have not been met. Therefore, we decided that the 
Plan has to pay for a determination of refractive state (92015), progressive lenses (V2781), polycarbonate 
lenses (V2784), and standard lenses (V2750) provided on September 8, 2022.  
 
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.