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

 
We decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic connection 
between wheelchair controller and two or more power seating system motors (E2311), a bag hooks (K0108), a 
power wheelchair accessory, expandable controller (E2377), a power wheelchair accessory, harness for 
upgrade to expandable controller (E2313) and a height panel bracket and microlight switch (K0108). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the requested items are 
medically necessary to improve your overall health and safety in your home. The Plan denied your request. The 
Plan says the requested items are not reasonable and necessary. 
 
The file shows that the Plan approved the wheelchair and some accessories for you. The records show that the 
light kit and the bag hooks do not serve a medical purpose and the upgraded electronics are not medically 
necessary and therefore not a covered item. This means that Medicare rules for coverage of wheelchair 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair accessory, electronic connection between wheelchair controller and two or more power seating 
system motors (E2311), a bag hooks (K0108), a power wheelchair accessory, expandable controller (E2377), a 
power wheelchair accessory, harness for upgrade to expandable controller (E2313) and a height panel bracket 
and microlight switch (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) to be 
provided by an oral surgeon. 
 
You asked the Plan to pay for the treatment of root canal obstruction. You say that you are in a lot of pain. You 
say that you need this root canal so you can have a partial denture made. The Plan denied your request. The 
Plan says this claim has been 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 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 
treatment of root canal obstruction (D3331) to be provided by an oral surgeon.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the neck and outpatient 
clinic visit (G0463) provided on September 30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CT of the neck and outpatient clinic visit. You say that you would like 
reconsideration because these services were medically necessary and provided in good faith. The Plan denied 
your request. The Plan says prior authorization was not 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 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 computed tomography (CT) of the neck and 
outpatient clinic visit (G0463) provided on September 30, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine venipuncture and laboratory services provided on 
January 6, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for routine venipuncture and laboratory services. You say that this provider regularly 
complies with all administrative requirements for payments. The Plan denied your request. The Plan says this 
provider, a non-participating provider, rendered the outpatient hospital visit services. The Plan also says that 
they followed up with the rendering provider's office on March 10, 2022, and was told that there is no referral 
by the primary care physician (PCP) for the rendering provider. The Plan also says that there are no 
authorizations on file from the PCP or to the rendering provider. 
 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 routine venipuncture and laboratory services 
provided on January 6, 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 a domiciliary or rest home visit provided on November 19, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that at the time of service, the member 
was residing at the facility and therefore, the rendering provider was not responsible to obtain authorization. 
You also say that the assisted living facility is responsible to obtain prior authorization for all of their patients, 
which should also cover for the medical treatment provided by the rendering provider. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the 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 domiciliary or rest home visit provided on 
November 19, 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 a joint injection procedure performed on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for the injection. You say that you did not have a copayment for 
these services before. 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 
copayment for surgery services at an outpatient hospital.  
 
You have been asked to pay a $100 copayment for the injection. The injection is considered a surgical 
procedure and falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
joint injection procedure performed on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for an onabotulinumtoxina 
(Botox) injection and administration provided on November 11, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the injection and administration. You say that 
you were informed of only a $45 copayment for the services. The Plan denied your request. The Plan says the 
correct copayment and coinsurance was applied. 
 
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 for specialist services provided in an office setting. Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Part B drug. 
 
You have been asked to pay a $35 copayment for the injection administration. The injection administration 
falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have 
also been asked to pay $364.80 for the Botox drug, which is 20% of the allowed amount ($1,824.00 allowed 
amount x 20% coinsurance = $364.80). The Botox drug falls within the Medicare Part B Prescription Drugs 
benefit category. The total for the visit is $399.80. 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 and 
coinsurance for an onabotulinumtoxina (Botox) injection and administration provided on November 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
January 2, 2022, to January 8, 2022. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that you could have left the hospital in a 
few days instead of staying for more than 5 days. The Plan denied your request. The Plan says the copayment 
amount you are being charged 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 $350 
copayment per day for days 1 to 5 and $0 copayment for additional days for in-network inpatient stay. This 
inpatient stay lasted 6 days, resulting in a copayment amount of $1,750. 
 
You have been asked to pay $350 copayment per day for days 1 to 5 and $0 copayment for additional days for 
inpatient stay. Inpatient stay falls within the Inpatient Hospital 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 an inpatient hospital stay provided from January 2, 2022, to January 8, 2022.  
 
Your complaint about being kept in the hospital longer than you felt was necessary 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from November 4, 2021, to November 21, 2021.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment per day for days 1-6 of Inpatient Hospital Care. 

The enrollee has been asked to pay a $1,350 copayment for 6 days of inpatient hospital care ($225 x 6 = $1,350). This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from November 4, 2021, to November 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 11, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that at the time of service, the member 
was residing at the facility and therefore, the rendering provider was not responsible to obtain authorization. 
You also say that the assisted living facility is responsible to obtain prior authorization for all of their patients, 
which should also cover for the medical treatment provided by the rendering provider. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the 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 domiciliary or rest home visit provided on 
October 11, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for continuous glucose monitor supplies 
(K0553) provided on January 7, 2022. 
 
You asked the Plan to waive the deductible for the continuous glucose monitor supplies. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to Durable medical equipment (DME) 
and related supplies.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable 
medical equipment (DME) and related supplies. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $500 deductible which applies to Durable medical equipment (DME) and related 
supplies. This cost sharing is a contractual obligation that had not been met at the time the continuous glucose 
monitor supplies was received on January 7, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for continuous glucose monitor supplies (K0553) provided on January 7, 2022.  
 
Since the $500 deductible was met, you have also been asked to pay a 4% coinsurance ($8.15). 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain pontic (D6241), and a crown-retainer (D6751) 
to be provided by a participating provider. 
 
You asked the Plan to pre-approve porcelain pontic and a crown-retainer. You say that these services are 
medically necessary. The Plan denied your request. The Plan says D6241 and D6751 are not covered dental 
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 pre-approve 
porcelain pontic (D6241), and a crown-retainer (D6751) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental extraction from an oral surgeon. 
 
You asked the Plan to pre-approve these services. You say that you have not seen a dentist and are at risk for 
infection if the tooth is not pulled. The Plan denied your request. The Plan says the services are 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. The Plan covers supplemental 
dental benefits from a general dentist only.  
 
We looked at the file and the Plans rules. You are requesting services from an oral surgeon. The Plan covers 
dental services from a general dentist only. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a dental extraction from an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the oral exam (D0120), prophylaxis (D1110), 
crown (D2740), and core build up (D2950) provided from June 30, 2021, to July 13, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you believe that you should be 
reimbursed for these services. You say that nowhere in the printed material does it say that a member has to know or be certain that a provider accepts or does not accept Medicare. You also say that you were reimbursed 
for dental work from this provider in 2020. The Plan denied your request. The Plan says the provider in this 
case has opted out of Medicare. The Plan also says that payment cannot be made to a provider that has opted 
out of Medicare. 
 
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, dental services provided by a dentist 
that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to reimburse you for the oral exam (D0120), prophylaxis (D1110), crown (D2740), and core 
build up (D2950) provided from June 30, 2021, to July 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs provided from October 6, 
2021, to November 17, 2021. 
 
You asked the Plan to waive the cost share for Part B drugs, intravenous therapy and chemotherapy. You say 
that you were informed the coinsurance would be waived for these services. The Plan denied your request. The 
Plan says the cost for intravenous therapy and chemotherapy were waived. The Plan also says the coinsurance 
for Part B drugs applied 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 chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B. 
 
You have been asked to pay a total of $2,111.22 for Part B drugs.  
 
Dates of Service Service Allowed Amount Standard 
Coinsurance 
Member Liability 
October 6, 2021- 
October 27, 2021 
Part B Drugs $6,110.01 20% $1,222.01 
November 3, 2021-
November 17, 2021 
Part B Drugs $5,614.18 20% $889.21 - Less than 
standard 20% 
TOTAL:    $2,111.22 
 
Part B drugs fall within the "Medicare Part B prescription drugs" 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 share for Part B drugs provided from October 6, 2021, to November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on September 20, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that at the time of service, the member 
was residing at the facility and therefore, the rendering provider was not responsible to obtain authorization. 
You also say that the assisted living facility is responsible to obtain prior authorization for all of their patients, 
which should also cover for the medical treatment provided by the rendering provider. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the 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 domiciliary or rest home visit provided on 
September 20, 2021, by an out-of-network (OON) provider.