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

 
We decided that the Plan does not have to pay for an office visit provided on May 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
 The Plan denied your request. The Plan says the services were obtained from an out-of-network (OON) 
provider and the services can be obtained from 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 an office visit provided on May 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 a chiropractic service provided on August 12, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a chiropractic service. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
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 chiropractic service provided on August 12, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pay for a CPAP device. You say that the item should be covered. The Plan denied your 
request. The Plan says the 13-month rental cap has been met for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that if the beneficiary accepts the purchase option, the 
DME MAC or A/B MAC (HHH) continues making rental payments until a total of 13 continuous rental 
months have been paid. The DME MAC or A/B MAC (HHH) will not make any additional rental payments 
beyond the 13th rental month. On the first day after 13 continuous rental months have been paid, the supplier 
must transfer title to the equipment to the beneficiary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device have not been met. Therefore, we decided that the Plan does not have to pay for a 
continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 31, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not receive transport or call the ambulance. You also say that they spoke with you and the staff but were not 
treated by the ambulance personnel. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 31, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on July 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occupied transit (K0108). 
 
You asked the Plan to pre-approve an occupied transit. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is not intended for use within the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve an occupied transit (K0108).
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 27, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
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 27, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on June 27, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was issued for use during 
surgery. The Plan denied your request. The Plan says the devices are not separately payable. The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The file shows that the durable medical equipment was provided for use in an ambulatory surgical center. 
Neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan 
does not have to pay for the pneumatic compression device and related supplies provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service should be covered. 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 date of service June 11, 2021. Therefore, 
we decided that the Plan does not have to pay for the dental services on June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
provided on September 21, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014). You say that you had to 
return multiple times for the same thing and was told by the office you would not be billed for copayment, and 
they still billed the copayment. 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 Medicare-covered eye examinations to diagnose and treat diseases and conditions of the eyes. 
 
You have been asked to pay a $45 copayment for a medical eye examination (92014). This item/service falls 
within the Medicare-covered eye examinations to diagnose and treat diseases and conditions of the eyes 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 medical eye examination (92014) provided on 
September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 30, 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 
September 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve visual field assessments (ForeseeHome age-related 
macular degeneration monitoring program). 
 
You asked the Plan to pre-approve the ForeseeHome age-related macular degeneration monitoring program. 
You say that you would like the denial for this service to be reversed, and approved for coverage. The Plan 
denied your request. The Plan says this service is investigational under all circumstances, and not covered by 
the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the ForeseeHome age-related macular 
degeneration monitoring program. Our reviewer says that the ForeseeHome age-related macular degeneration 
monitoring program not considered medically reasonable and necessary in this case. Our physician reviewer 
found the ForeseeHome age-related macular degeneration monitoring program is considered 
investigational/experimental as additional clinical studies are needed to demonstrate that it affects visual 
outcomes. 
 
 
 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 ForeseeHome age-related macular degeneration monitoring program have 
not been met. Therefore, we decided that the Plan does not have to pre-approve visual field assessments 
(ForeseeHome age-related macular degeneration monitoring program).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 22, 2022. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
June 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 19, 2022, 
to March 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date was not reported correctly on 
either the subsequent claim at issue or the NOA submitted. Therefore, we decided that the Plan does not have 
to pay for the home health services provided from February 19, 2022, to March 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the reports attached support the services provided. 
The Plan denied your request. The Plan says there is no authorization on file for the services 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 an office visit provided on July 29, 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 an acute inpatient psychiatric level of care from 
December 15, 2022, and forward. 
 
You asked the Plan to pre-approve an acute inpatient psychiatric level of care. You say that you would like the 
Plan to reverse their original decision, and authorize payment for the enrollee's entire period of stay. The Plan 
denied your request. The Plan says the enrollee does not meet medical necessity criteria for an acute inpatient 
level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an acute inpatient psychiatric level of 
care. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric 
care. Our physician reviewer found that it is not expected that the enrollee will improve in a reasonable period 
of time beyond the date in question as the enrollee was not showing any dangerousness to self or others, 
auditory or visual hallucinations, or aggressive behaviors. The enrollee was cooperative and compliant with 
medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower 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 an acute inpatient psychiatric level of care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an acute inpatient psychiatric level of care from December 
15, 2022, and forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on August 30, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit provided on November 22, 2022. 
 
You asked the Plan to pay for psychotherapy visit. You say that your visits have been covered by your 
insurance, so you would like them to cover this visit as well. 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 psychotherapy visit 
provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on October 06, 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 
October 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for acupuncture for lower back pain provided 
on October 25, 2022. 
 
You asked the Plan to waive the coinsurance for acupuncture for lower back pain. You say that you disagree 
with the copayment. 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 acupuncture for lower back pain.  
 
You have been asked to pay a 20% coinsurance for acupuncture for lower back pain. The total allowed amount 
for the acupuncture is $90 ($90 x 20% = $18). However, you are only being asked to pay $15.92 which is less 
than the required amount. This item/service falls within the acupuncture for lower back pain 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 acupuncture for lower back pain provided on October 25, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 22, 
2022. 
 You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan, the surgical 
placement of an implant body, bone graft, and fixed partial denture (D6104, D0366, D6010, D9120) provided 
on September 14, 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 cone 
beam computed tomography (CT) scan, the surgical placement of an implant body, bone graft, and fixed partial 
denture (D6104, D0366, D6010, D9120) provided on September 14, 2022.