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

 
We decided that the Plan does not have to waive the copayments for specialist visits provided from April 12, 
2022, to June 24, 2022. 
 
You asked the Plan to waive the copayments for specialist visits. You say that you feel the services should be 
covered because the claims are causing you financial hardship. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each covered visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a total copayment of $135 for specialist visits ($45 per visit x 3 visits = $135). 
This item/service falls within the Physician/Practitioner 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 copayments for specialist visits provided from April 12, 2022, to June 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on May 25, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4261), bone replacement graft 
(D4263), and guided tissue regeneration (D4266) provided on July 15, 2022. 
 
You asked the Plan to pay for the osseous surgery, bone replacement graft, and guided tissue regeneration. You 
say that these procedures should be considered preventive care and medically necessary to save a natural tooth. 
The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. 
 
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 
osseous surgery (D4261), bone replacement graft (D4263), and guided tissue regeneration (D4266) provided on 
July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses (V2510) purchased on July 18, 2022. 
 You asked the Plan to pay for the contact lenses. You say that these medically necessary contacts were not 
billed correctly. You also say that you still have the same disease now as you did in the past. The Plan denied 
your request. The Plan says this item is not covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. The record shows 
that the Plan contacted the provider who advised you were informed of your options, and that the provider does 
not accept your vision insurance. The record also shows that you signed an agreement of financial 
responsibility acknowledging your insurance benefits and payment responsibility. Therefore, we decided that 
the Plan does not have to pay for the contact lenses (V2510) purchased on July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral imaging (D0350), panoramic radiographic image 
(D0330), intraoral imaging (D0210), fluoride varnish (D1208), and oral hygiene instructions (D1330), provided 
by an out-of-network provider on July 13, 2022, to July 15, 2022. 
 
You asked the Plan to pay for dental services. You say that you do not know why you are being charged for 
this. The Plan denied your request. The Plan says the rendered dental services are not covered 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 2D oral 
imaging (D0350), panoramic radiographic image (D0330), intraoral imaging (D0210), fluoride varnish (D1208), and oral hygiene instructions (D1330), provided by an out-of-network provider on July 13, 2022, to 
July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sequestrectomy (D7550) provided on July 18, 2022. 
 
You asked the Plan to pay for the sequestrectomy. You say that this service was medically necessary and 
should be covered. The Plan denied your request. The Plan says a sequestrectomy (D7550) is not covered by 
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 the 
sequestrectomy (D7550) provided on July 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lift recliner provided on April 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a lift recliner. You say that you spoke to someone at the Plan about acquiring the 
chair and she sent you a hard copy list of DME providers in your area. You also say you called them all and 
they all said that they no longer carried the chairs. You are requesting an appeal. The Plan denied your request. 
The Plan says you must receive your care from a network 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 a lift recliner provided on April 22, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee must receive care from a network 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 an office visit provided on March 28, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 10, 2022 and 
March 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the claim was denied in error. The Plan denied 
your request. The Plan says the services must be provided by a network 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 laboratory services provided on February 10, 2022 
and March 24, 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehabilitation to regain their 
strength before going home. The Plan denied your request. The Plan says the Medicare criteria for IRF 
admission were not met and the enrollee can receive the skilled therapy services they need at a skilled nursing 
facility (SNF). 
 
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 that the clinical documentation shows that the enrollee has active medical 
comorbidities. However, the enrollee does not have complex functional deficits specified and evaluating 
therapists. Recommend SNF or lower-level intensity therapy thus the enrollee would not be expected to require 
or tolerate intense therapy of 15 hours of therapy per week. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the radiation therapy services provided on 
June 8, 2022, June 9, 2022, June 10, 2022, June 13, 2022, and June 14, 2022. 
 
You asked the Plan to waive the copayments for the radiation therapy services. You say that a copayment 
should not be charged for each treatment. 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 $60 
copayment for radiation therapy. There was a total of 5 visits with a copayment of $60 for each visit. The total 
copayment amount for all the dates of service is $300 (5 visits x $60 copayment). 
 
  You have been asked to pay a $300 copayment for the radiation therapy services. This item/service falls within 
the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for the radiation therapy services provided on June 8, 2022, June 9, 2022, June 10, 
2022, June 13, 2022, and June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies (K0553), provided on March 30, 2022. 
 
You asked the Plan to pay for the diabetic supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says there is not a valid proof of delivery. 
 
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. Neither the shipping 
or delivery date match the date of service. 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 
diabetic supplies (K0553), provided on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional single vision lens (V2100) and frames (V2020) 
purchased on January 27, 2022. 
 
You asked the Plan to pay for the additional eyewear. You say that you feel this claim should not have been 
denied since the provider was recommended by the insurance company. The Plan denied your request. The 
Plan says on this date of service the enrollee purchased two pairs of glasses, but only one pair of glasses is 
covered after cataract surgery. The Plan also says no reimbursement will be provided for the additional 
eyewear. 
 
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 one pair of eyeglasses or contact lenses after each cataract surgery. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that the enrollee purchased two pairs 
of glasses on this date of service. The Plan paid for one pair of glasses, exhausting the enrollee's benefit. Based 
on this information, we decided that the Plan's rules for coverage of the additional eyewear have not been met. 
Therefore, we decided that the Plan does not have to pay for the additional single vision lens (V2100) and 
frames (V2020) purchased on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the best level of therapy so you can get 
back to your normal daily living. The Plan denied your request. The Plan says the Medicare guidelines for IRF 
admission were not met and the enrollee can receive the services that they need in a skilled nursing facility. 
 
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 that the clinical documentation shows that the enrollee has functional impairments. 
However, there are no complex functional deficits specified thus would not be expected to require intense 
therapy or inter-disciplinary team management of rehabilitation in an IRF setting. The complexity of the 
enrollee's nursing, medical and rehabilitation needs documented would not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 6, 2022, to June 
4, 2022. 
 
You asked the Plan to pay for the billed services. You say that the notice of admission was submitted in a 
timely manner. The Plan denied your request. The Plan says the claim does not have a matching admission 
date. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The admission date of service on the final claim does not match the date of 
admission on the NOA. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from May 6, 2022, to June 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for Medicare Part B 
prescription drugs and a specialist office visit provided on July 20, 2022 
 
You asked the Plan to waive the copayment and coinsurance for Medicare Part B prescription drugs and a 
specialist office visit. You say that you say you cant afford to pay this 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 a 20% 
coinsurance for Medicare Part B prescription drugs and a $35 copayment and a physician/practitioner 
services/specialist visit.  You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $35 copayment 
and a specialist office visit. The total allowed amount for the Medicare Part B drugs $1,375.70. You are being 
asked to pay $275.14 ($1,375.70 x 20% = $275.14). The total amount you are being asked to pay $310.14 
($275.14 + $35 =$310.14). 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 Medicare 
Part B prescription drugs and a specialist office visit provided on July 20, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breathing capacity test provided on 
 April 20, 2022. 
 
You asked the Plan to waive the copayment for a breathing capacity test. You say that you should not be 
responsible to pay this. 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 $50 
copayment for Medicare-covered diagnostic tests.  
 
 
 
 You have been asked to pay $33.42 for a breathing capacity test, which is less than the standard $50 
copayment. This item/service falls within the outpatient diagnostic 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 copayment for a breathing capacity test provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you were told the provider was in-network so you feel 
you should not have to pay for the visit. The Plan denied your request. The Plan says the service can be 
provided by an in-network 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 office visit provided on September 20, 2022, by an 
out-of-network (OON) provider.