Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete lower denture (D5120) provided on September 
21, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were told the provider was an in-network 
provider and you would like to get back the balance that you paid. 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 a complete lower denture (D5120) provided on September 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is ready to be released from the hospital 
and his medical condition does not allow him to be transported home. The Plan denied your request. The Plan 
says the SNF care is not medically necessary, and the enrollee's needs can be met at a lower level of care such 
as a long-term care facility. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for accupuncture and manual adjustment visits provided on May 
25, 2022, to September 13, 2022. 
 
You asked the Plan to pay for accupuncture and manual adjustment visits. You say that you did not know that 
this provider was out of network. 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 accupuncture and 
manual adjustment visits provided on May 25, 2022, to September 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure under the enrollees medical benefits. 
 
You asked the Plan to pre-approve Ensure under the enrollees medical benefits. You say that the item is 
medically necessary. The Plan denied your request. The Plan says Ensure can be ordered through the enrollees 
supplemental over-the-counter benefit, which does not require pre-approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Ensure under the enrollees medical benefits.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on 
September 30, 2022. 
 
You asked the Plan to waive the copayment for emergency room visit. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency room visit. This item/service falls within the 
emergency 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 emergency room visit 
provided on September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection of laboratory specimens and travel allowance 
provided on June 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for collection of laboratory specimens and travel allowance. 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 provided. 
 
 
 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 collection of laboratory specimens and travel 
allowance provided on June 23, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection of laboratory specimen and travel allowance 
provided on May 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for collection of laboratory specimen and travel allowance. You say that the records 
attached support the services provided. The Plan denied your request. The Plan says there is no prior 
authorization on file for the services 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 collection of laboratory specimen and travel 
allowance provided on May 12, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided 
on August 5, 2022, to August 26, 2022. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree 
with the copayments. 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 $35 
copayment per visit for outpatient rehabilitation services.  
 
You have been asked to pay a $35 copayment per visit for outpatient rehabilitation services. The total amount 
you are being asked to pay is $122.77 which is less than the required amount. This item/service falls within the 
outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
outpatient rehabilitation services provided on August 5, 2022, to August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation-diagnostic service provided by dentist or 
physician other than practitioner providing treatment (D9310) provided on April 20, 2022. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the Plan not paying this 
claim. The Plan denied your request. The Plan says this service is not covered under your 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. Consultation-diagnostic 
service provided by dentist or physician other than practitioner providing treatment (D9310) is not covered 
under the Plans dental benefits. 
 
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 
consultation-diagnostic service provided by dentist or physician other than practitioner providing treatment 
(D9310) provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on October 13, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for outpatient hospital services. 
 
You have been asked to pay a $50 copayment for office visit. This item/service falls within the outpatient 
hospital services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for office visit provided 
on October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that bilevel positive airway pressure (BiPAP) 
and average volume-assured pressure support (AVAPS) have been proven to be ineffective. The appellant says 
that denying the requested device will be life threatening to the enrollee. The Plan denied your request. The 
Plan says the requested home mechanical ventilator would be set in targeted tidal volumes and volume-assured 
pressure support (TTV-VAPS) mode with Auto-expiratory positive airway pressure (EPAP) that could be 
delivered by bilevel positive airway pressure (BiPAP) and is therefore non-covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically necessary.  The enrollee has severe chronic obstructive pulmonary disease (COPD) and Heart failure 
with preserved ejection fraction (HFpEF), with recurrent hospitalizations. Arterial Blood Gasses (ABGs) in 
hospital are consistent with acute on chronic hypercarbic respiratory failure.  The ordering physician's appeal 
note indicates the enrollee has been tried on BiPAP with average volume-assured pressure support (AVAPS) as 
an outpatient and this failed.  However, this is not documented in the medical record.  There is no ABG done as 
an outpatient, while the patient is stable and using BiPAP with AVAPS during sleep.  There is no device 
download documenting sufficient use of the device.  Battery backup and alarms are not necessary for this 
patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85027 provided on August 12, 2022. 
 
You asked the Plan to pay for procedure code 85027. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, procedure code 85027, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for procedure code 85027 provided on August 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for physical therapies provided on February 23, 
2022, to June 17, 2022. 
 
You asked the Plan to reduce the cost share for physical therapies. You say that the copayment had been $35 
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 50% 
coinsurance for outpatient rehabilitation services.  
 
You have been asked to pay 50% coinsurance for each out-of-network physical therapy. This item/service falls 
within the outpatient rehabilitation 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 reduce the cost share 
for physical therapies provided on February 23, 2022, to June 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 11, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you think this is too high of a 
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 $325 
copayment per one-way trip for Medicare-covered ambulance services.  
 
You have been asked to pay a $325 copayment for ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on August 11, 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 10, 2022, 
to March 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that you were never told you needed a referral 
to get the home health care. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from February 
10, 2022, to March 4, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120) provided on July 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received a set of dentures that your 
previous provider was unable to correct. You also say the provider refused to begin anew. 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 July 22, 2021. Therefore, 
we decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120) provided on July 6, 2022.  
 Your complaint about the potentially poor quality of services from the previous provider 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network annual wellness visit 
provided on August 17, 2022. 
 
You asked the Plan to waive the coinsurance for an out-of-network annual wellness visit. You say that you 
should not have to pay more than the copayment amount for a coinsurance. 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 40% 
coinsurance for annual wellness visit. The allowed amount of this service is $152.85, resulting in a coinsurance 
amount of $61.14 ($152.85 x 40% = $61.14). 
 
You have been asked to pay a $61.14 coinsurance for an out-of-network annual wellness visit. This 
item/service falls within the annual wellness visit 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 an out-of-network annual wellness visit provided on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy of the nails provided on July 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for biopsy of the nails. 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 
provided. 
 
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 biopsy of the nails provided on July 14, 2022, by 
an out-of-network (OON) provider.