Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from August 1, 2022, 
to August 5, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you left the facility on August 4, 2022 
but was charged a copayment for August 5, 2022. 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 $0 
copayment per day, per admission for days 1-20 and a $100 copayment per day, per admission for days 21-100 
for skilled nursing facility (SNF) care.  
 
 
  You have been asked to pay a $100 copayment for day 21 of a SNF stay. This item/service falls within the 
skilled nursing facility (SNF) 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 a 
SNF stay provided from August 1, 2022, to August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on October 
13, 2022. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that the records attached support 
the services provided. 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 a subsequent nursing 
facility care visit provided on October 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 20, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from February 20, 2023, forward. You say that the 
services are medically necessary. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
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 inpatient psychiatric care from 
February 20, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient 
mental health treatment beyond the date in question of February 20, 2023, forward. Our physician reviewer 
found it appears that the enrollee has reached maximum benefit from the inpatient psychiatric stay. The 
enrollee continues to have fragmented thoughts with poor insight and judgment but has not exhibited any self-
harming behaviors. The progress notes do not indicate that the enrollee has been aggressive with peers or staff 
on the unit or has had any recent attempt to harm herself during the disputed period. As of the last covered day, 
there is no indication in the available medical records that the enrollee's psychiatric symptoms could not be 
managed on a less restrictive basis. As of the last covered day the enrollee did not express any active suicidal 
ideation or intent, or any intent to harm themselves or anyone else. The enrollee had no acute psychiatric issues 
that would require continued inpatient care. The enrollee has chronic symptoms. The available medical records 
do not support that continued inpatient care will change these symptoms or the enrollee's current condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from February 20, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 20, 
2023, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under codes 87798, and 87481 
provided on April 28, 2022. 
 
You asked the Plan to pay for laboratory services billed under codes 87798, and 87481. 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 laboratory services 
billed under codes 87798, and 87481 provided on April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
October 26, 2022 and October 28, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by an ineligible provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810, 
97811) provided on October 26, 2022 and October 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you have pain every time you walk. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
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 pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care services provided on September 16, 2022. 
 
You asked the Plan to pay for principal care services. You say that the records attached support the services 
provided. 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 principal care services 
provided on September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots and deep sedation/general 
anesthesia (D9222, D7250, D9223) provided on October 17, 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 the 
removal of residual tooth roots and deep sedation/general anesthesia (D9222, D7250, D9223) provided on 
October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid and dispensing fee provided on April 4, 2022. 
 
You asked the Plan to pay for a hearing aid and dispensing fee. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says hearing aids must be purchased through the Plan hearing 
providers to be covered under the hearing aid services offered by the member's Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are purchased from an in-network Plan hearing provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid and dispensing fee have not been met. Therefore, we decided that the Plan does not 
have to pay for a hearing aid and dispensing fee provided on April 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on September 30, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your 
request. The Plan says your diagnosis was a fall, the available information shows that you were evaluated, and 
you declined transport to the emergency room. The Plan also says this request is 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 September 30, 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 (A0998) provided on September 30, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an emergency room visit provided from August 9, 
2022, to August 10, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you disagree with the 
charges, and you do not know why you are getting billed. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for in-network emergency services.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $90 
copayment for in-network emergency services. The Plan contract does not clearly say how much enrollees 
must pay for in-network emergency services. This means that the Plan did not follow Medicare rules for 
disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for an 
emergency room visit provided from August 9, 2022, to August 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory testing provided on August 8, 
2022. 
 
You asked the Plan to waive the copayment for lab testing. You say that the services should be fully covered as 
part of your routine annual wellness checkup. 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 
copayment for lab services provided in an in-network outpatient hospital facility setting. These services were 
not routine lab services. 
 
You have been asked to pay a $40 copayment for lab testing. This item/service falls within the lab services 
provided in an in-network outpatient hospital facility setting 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 laboratory testing provided on August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthopedic footwear coded as L3215 provided on 
September 26, 2022. 
 
You asked the Plan to pay for procedure code L3215. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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. The rules also say 
that orthopedic footwear billed using code L3215 will be denied as non-covered.  Therefore, we decided that 
the Plan does not have to pay for the orthopedic footwear coded as L3215 provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous supplies and equipment (code A9270) and 
vision item or service, miscellaneous (code V2799) provided on October 3, 2022. 
 
You asked the Plan to pay for miscellaneous supplies and equipment (code A9270) and vision item or service, 
miscellaneous (code V2799). The Plan denied your request. The Plan says miscellaneous supplies and 
equipment (code A9270) and vision item or service, miscellaneous (code V2799) are non-covered services. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that providers 
must report services correctly. Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of miscellaneous supplies and equipment (code A9270) and vision item or service, miscellaneous 
(code V2799) have not been met. Therefore, we decided that the Plan does not have to pay for miscellaneous supplies and equipment (code A9270) and vision item or service, miscellaneous (code V2799) provided on 
October 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
November 09, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with the 
copaymet. 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 $175 
copayment for Outpatient hospital services/advanced imaging. 
 
You have been asked to pay a $175 copayment for outpatient hospital services. This item/service falls within 
the Outpatient hospital services/advanced imaging 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 hospital services provided on November 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for bitewings (D0274), a periodic oral evaluation (D0120), 
and intraoral imaging (D0220/D0230), provided on October 5, 2022, to October 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this provider used to be in-network. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for bitewings (D0274), a periodic oral 
evaluation (D0120), and intraoral imaging (D0220/D0230), provided on October 5, 2022, to October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a therapeutic continuous glucose monitor (CGM) provided on October 
3, 2022. 
 
You asked the Plan to pay for a CGM. You say that all appropriate evidence was provided. The Plan denied 
your request. The Plan says that this claim has been correctly denied. 
 
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 contain a valid physician order and proof of delivery. The delivery form submitted includes all 
of the needed data elements for Proof of Delivery (POD) according to Medicare rules.. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan has to pay for a therapeutic continuous glucose monitor (CGM) provided on October 3, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete bilateral study (93970) provided on July 9, 
2022. 
 
You asked the Plan to pay for the complete bilateral study. The Plan denied your request. The Plan says in the 
absence of clinical information, medical necessity and coverage cannot be determined. The Plan also says with 
the information provided, it cannot be determined how the enrollee came to the servicing provider, or whether 
the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the complete bilateral study have been 
met. Medical records were not provided for this case. Without medical records, we are unable to determine if 
these services were medically necessary, or if the enrollee meets the criteria for coverage. Therefore, we 
decided that the Plan does not have to pay for the complete bilateral study (93970) provided on July 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutments on tooth #6, 19, and 20 
(D6057) and abutment supported crowns on tooth #6, 19, 20 (D6058) provided on August 30, 2022. 
 
You asked the Plan to pay for the abutments and supported crowns. You say that it was your understanding that 
the Plan paid for crowns. The Plan denied your request. The Plan says that custom fabricated abutments 
(D6057) and abutment supported crowns (D6058) are 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 custom 
fabricated abutments on tooth #6, 19, and 20 (D6057) and abutment supported crowns on tooth #6, 19, 20 
(D6058) provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97813, 97814) provided on  
July 22, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by an ineligible provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that you are not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97813, 97814) 
provided on July 22, 2022.