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

 
We decided that the Plan does not have to waive the coinsurance for the denosumab injection, drug 
administration, and specialist office visit provided on October 4, 2022. 
 
You asked the Plan to waive the coinsurance for the injection, drug administration, and office visit. You say 
that you had prior authorization for these services. 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 20% 
coinsurance for Medicare Part B drugs and drug administration. Your contract with the Plan also clearly says 
that you must pay 20% coinsurance for each specialist office visit. 
 
You have been asked to pay $267.12, which 20% coinsurance of the allowed amount for the injection 
($1,335.60 allowed amount x 20% coinsurance = $267.12). You have also been asked to pay $2.84, which is 20% coinsurance of the allowed amount for the drug administration ($14.18 allowed amount x 20% 
coinsurance = $2.84). These items/services fall within the Medicare Part B drugs and drug administration 
benefit category.  
 
You have also been asked to pay $33.77, which is 20% coinsurance of the allowed amount for the specialist 
visit ($168.83 allowed amount x 20% coinsurance = $33.77). This item/service falls within the 
physician/practitioner services benefit category. You have been asked to pay a total of $303.73 ($267.12 
coinsurance + $2.84 coinsurance + $33.77 coinsurance = $303.73). This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the denosumab injection, drug administration, and specialist office visit provided on October 4, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rebased complete mandibular denture (D5711) provided on 
November 7, 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 the services denied correctly as they do not fall 
within your dental 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. Therefore, we decided that the Plan does not have to pay for a rebased 
complete mandibular denture (D5711) provided on November 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation, extraction, intraoral x-ray, bone 
replacement graft, unlisted special procedure, intravenous moderate sedation, and an occlusal adjustment 
(D9310, D7210, D0220, D7953, 99199, D9239, D9951) provided on October 31, 2022, to December 1, 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 the services denied correctly as they do not fall 
within plan dental benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a dental consultation, extraction, 
intraoral x-ray, bone replacement graft, unlisted special procedure, intravenous moderate sedation, and an 
occlusal adjustment (D9310, D7210, D0220, D7953, 99199, D9239, D9951) provided on October 31, 2022, to 
December 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiologic monitoring provided on September 
19, 2022. 
 
You asked the Plan to pay for the remote physiologic monitoring. You say that the services were medically 
necessary. 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 remote physiologic 
monitoring provided on September 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on August 27, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment provided on August 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee may receive their care from a network provider, like when the 
enrollee gets a referral from their primary care physicain (PCP) to see a network specialist. (For more 
information about this, see Section 2 in Chapter 3.) On the other hand, the enrollee may choose to use their 
plans Point-of-Service (POS) option to see a network specialist without a referral. The enrollee may also use 
their POS option to see an out-of-network provider (a provider who is not part of the plans network) for most 
covered services. Out-of-network providers must be Medicare certified. Except in limited circumstances, 
services from Medicare-excluded or Medicare-opt-out providers are not covered by the plan. Keep in mind that 
prior authorization rules may still apply for services received using the enrollees POS option. Also, the care the 
enrollee receives from an out-of-network provider, or a network specialist without a referral, may cost more. 
 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot x-rays provided on August 02, 2022. 
 
You asked the Plan to pay for the foot x-rays. You say that the services were medically necessary. 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 foot x-rays provided 
on August 02, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B Prescription Drugs, 
radiation therapy, surgical supplies, non-radiological services and a specialist office visit provided on August 
25, 2022. 
 You asked the Plan to waive the cost share for Medicare Part B Prescription Drugs, radiation therapy, surgical 
supplies, non-radiological services and a specialist office visit. You say that you disagree with 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 20% 
coinsurance for Medicare Part B Prescription Drugs, a $25 copayment for outpatient diagnostic tests/Medicare-
covered radiation therapy service, a 20% coinsurance for outpatient diagnostic tests/ /surgical supplies, a 10% 
coinsurance for outpatient diagnostic tests/Medicare-covered non-radiological diagnostic services and a $25 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B Prescription Drugs, a $25 copayment for 
outpatient diagnostic tests/Medicare-covered radiation therapy service, a 20% coinsurance for outpatient 
diagnostic tests/ /surgical supplies, a 10% coinsurance for outpatient diagnostic tests/Medicare-covered non-
radiological diagnostic services and a $25 copayment for physician/practitioner services/specialist. The total 
allowed amount for the prescription drugs $246. You are being asked to pay $49.20 ($246 x 20% $49.20). The 
amount you are being asked to pay for the radiation therapy is $6.23 which is less than the required amount.  
The total allowed amount for the surgical supplies is $222.20. You are being asked to pay $44.44. The total 
amount you are being asked to pay diagnostic test $2.15 which is less than the 10% coinsurance. You are being 
asked to pay $18.77 for the specialist office visit which is less than the required amount. The total amount you 
are being asked to pay is $120.79 ($18.77+ $2.15 + $44.44 +$49.20 + $6.23 =$120.79). 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 Medicare Part B Prescription Drugs, radiation therapy, surgical 
supplies, non-radiological services and a specialist office visit provided on August 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the electrophysiologic evaluation provided 
on August 3, 2022. 
 
You asked the Plan to waive the coinsurance for the electrophysiologic evaluation. You say that this should 
only have a copayment amount. 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 20% 
coinsurance for Medicare-covered outpatient diagnostic tests.  
 
You have been asked to pay 20% coinsurance for the electrophysiologic evaluation. Due to meeting your out-
of-pocket maximum you are only being asked to pay $1,953.93. 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 coinsurance 
for the electrophysiologic evaluation provided on August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the specialist office visits provided from 
January 5, 2022, to November 3, 2022. 
 
You asked the Plan to reduce the coinsurance for the specialist office visits. You say that you were told the 
services were received from an in-network provider. 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 45% 
coinsurance per provider, per day, for each OON Medicare-covered specialist office visit.  
 
You have been asked to pay 45% coinsurance for the OON specialist office visits.  
 
Date of service Item Allowed Amount 45% Coinsurance 
01/05/2022 OON Specialist visit $75.25 $33.86 02/17/2022 OON Specialist visit $46.49 $20.92 
06/30/2022 OON Specialist visit $74.91 $33.71 
10/13/2022 OON Specialist visit $74.91 $33.71 
11/03/2022 OON Specialist visit $46.49 $20.92 
 
These items/services fall within the physician/practitioner services, including doctors office visits 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 reduce the coinsurance for the specialist office visits provided from 
January 5, 2022, to November 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abdominal ultrasound provided on September 02, 2022. 
 
You asked the Plan to pay for an abdominal ultrasound. You say that this was medically necessary and should 
be covered. 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 an abdominal ultrasound 
provided on September 02, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the review has determined that the record did not show that it is reasonable to expect that your necessary hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 10, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services are medically necessary. 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 laboratory services 
provided on November 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services and transthoracic echocardiogram 
(TTE) provided on August 15, 2022. 
 
You asked the Plan to pay for the laboratory services and transthoracic echocardiogram (TTE). You say that 
the services were medically necessary. 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 laboratory services 
and transthoracic echocardiogram (TTE) provided on August 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the outpatient surgery, physical therapy, 
occupational therapy, lab services, and Medicare Part B drugs provided from November 22, 2022, to December 
1, 2022. 
 
You asked the Plan to waive the cost share for the items/services. You say that these should not have a charge 
since you were in the hospital. 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 in-network outpatient surgery at an outpatient hospital. Your plan also clearly says that you pay 
a $35 copayment for each in-network physical therapy or occupational therapy visit. Your contract also clearly 
says that enrollees must pay a $15 copayment for in-network laboratory services. Your contract with the Plan 
also clearly says that enrollees must pay 20% coinsurance for Medicare Part B drugs. 
 
You have been asked to pay a $250 copayment for the outpatient surgery provided on November 22, 2022. 
Outpatient surgery falls within the outpatient surgery benefit category. You have also been asked to pay up to a 
$35 copayment for each physical and occupational therapy visit provided from November 23, 2022, to 
November 30, 2022. Outpatient therapy falls within the outpatient rehabilitation services benefit category. You 
have also been asked to pay up to a $15 copayment for each lab service provided from November 26, 2022, to 
December 1, 2022. Lab services fall within the outpatient diagnostic testing and services benefit category. 
 
You have also been asked to pay 20% coinsurance of the allowed amount for the Medicare Part B drugs 
provided on November 23, 2022. These items/services fall within the Medicare Part B 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 the outpatient surgery, physical therapy, occupational 
therapy, lab services, and Medicare Part B drugs provided from November 22, 2022, to December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home, or custodial care visit (code 99336) 
provided on November 30, 2022. 
 
You asked the Plan to pay for the domiciliary, rest home, or custodial care visit. The Plan denied your request. 
The Plan says 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 Plan says that the Plan has also determined that these 
services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home, or custodial care visit (code 99336) 
provided on November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry visit provided on September 03, 2022. 
 
You asked the Plan to pay for podiatry visit. You say that you are requesting reconsideration. 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 podiatry visit provided 
on September 03, 2022.