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

 
We decided that the Plan does not have to pay for nursing facility care provided on September 15, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that the service was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on September 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an ER visit and self-administered drugs provided 
from September 13, 2022, to September 14, 2022. You asked the Plan to waive the cost for an ER visit and self-administered drugs. You say that you feel the 
service should be covered as an inpatient hospital stay. The Plan denied your request. The Plan says this cost 
sharing was charged correctly for the ER visit and self-administered drugs are not covered by Part B. 
 
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 emergency room services.  
 
You have been asked to pay a total of $108.05 for an ER visit and self-administered drugs. The total includes a 
$50 copayment for an ER visit and $58.05 for self-administered drugs. The ER visit falls within the Emergency 
Care and Outpatient Hospital Services benefit categories. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost for an 
ER visit and self-administered drugs provided from September 13, 2022, to September 14, 2022.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on February 15, 2022. 
 
You asked the Plan to pay for imaging services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for imaging services provided on February 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on August 30, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that this should be covered. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on August 30, 2022.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on December 13, 2021. 
 
You asked the Plan to pay for imaging services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for imaging services provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral imaging 
(D0220), provided on October 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 January 14, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral 
imaging (D0220), provided on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) device and supplies 
provided on September 7, 2022. 
 
You asked the Plan to pay for a CGM device and supplies. You say that proof of delivery was provided. The 
Plan denied your request. The Plan says a valid proof of delivery was not provided. 
 
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. The delivery form does not include evidence of delivery 
of the specific items billed on this claim to the enrollee. 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 a continuous glucose monitor (CGM) device and supplies provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 25, 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 service is not a covered benefit. 
 
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 dental 
services on October 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the injections and self-administered drugs 
provided on November 17, 2022.  You asked the Plan to waive the cost for the injections and self-administered drugs. You say that these should 
be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly for the 
injections and self-administered drugs are not covered by Part B. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The rules say that Medicare Part B generally does not pay for self-
administered drugs. Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare 
Part B prescription drugs and that self-administered drugs are not covered. 
 
You have been asked to pay $358.17, which is 20% of the allowed amount for the injections. You have also 
been asked to pay $6.40 for the self-administered drugs. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost for the 
injections and self-administered drugs provided on November 17, 2022.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye exam provided on  
November 1, 2022. 
 
You asked the Plan to waive the copayment for a medical eye exam. You say that you have been charged an 
extra $40 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 $35 
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes.  
 
You are not being billed separately for a routine eye exam. You have been asked to pay a $35 copayment for a 
medical eye exam (92014). This item/service falls within the Medicare-covered eye exams 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 exam provided on November 1, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 16, 2022, to 
March 28, 2022. 
 
You asked the Plan to pay for home health services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 9, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for home health services 
provided from March 16, 2022, to March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
October 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that these exams/evaluations were performed by two 
different dentists for two different conditions. 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 January 12, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on October 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy visits provided from January 4, 2022, to 
January 6, 2022, by an OON provider. 
 
You asked the Plan to pay for physical therapy visits. You say the facility was informed that no authorization 
was required for outpatient therapy. You say that the clinical documents indicate the services were medically 
necessary and you are requesting full coverage. The Plan denied your request. The Plan says OON providers 
are 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 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 physical therapy visits provided from January 4, 
2022, to January 6, 2022, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from August 3, 2022, 
to August 16, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that there should not be a copayment due 
because the enrollee was not in a SNF facility more than 21 days. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment per day for days 1-20 and a $100 copayment per day for days 21-100 for each SNF 
admission per benefit period.  
 
 
  The enrollee has been asked to pay a total copayment of $600 for a SNF stay ($100 per day x 6 days = $600). 
This item/service falls within Skilled Nursing Facility Care benefit category. This means that the enrollee has 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for a SNF stay provided from August 3, 2022, to August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
panoramic x-ray (D0330) provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that if you would of went to the hospital the Plan 
would have paid more for these services. The Plan denied your request. The Plan says these services are not 
covered by the Plan's 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 
problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on December 13, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, problem focused (D0140) provided 
on October 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you realize your current plan only allows for 
two procedures per plan year. You also say that this was a special situation that could not wait for the new year. 
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 October 26, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation, problem focused 
(D0140) provided on October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a labial veneer (D2962) for tooth #10 provided on October 
17, 2022. 
 
You asked the Plan to pay for the dental service. You say that the enrollee's previous veneer fractured, and they 
needed a replacement. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the labial veneer is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a labial 
veneer (D2962) for tooth #10 provided on October 17, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 16, 2022. 
 
You asked the Plan to pay for ambulance services. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on July 13, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on July 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), polycarbonate lenses (V2784) and 
spherocylinder single vision (V2103) provided on September 30, 2022.  
You asked the Plan to pay for frames (V2020), polycarbonate lenses (V2784) and spherocylinder single vision 
(V2103). You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
per the members benefits, the plan coverage is limited to 1 pair of lenses and frames every 2 years. The Plan 
also says that they issued payment for the first eyewear purchased from the supplier on date of service April 07, 
2021. 
 
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 lenses and frames every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover one pair of lenses and frames every 
two years. This benefit was exhausted on April 7, 2021. Based on this information, we decided that the Plan's 
rules for coverage of frames (V2020), polycarbonate lenses (V2784) and spherocylinder single vision (V2103) 
have not been met. Therefore, we decided that the Plan does not have to pay for frames (V2020), polycarbonate 
lenses (V2784) and spherocylinder single vision (V2103) provided on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an osseous surgery (D4261), and a bone replacement graft 
(D4263) provided on September 28, 2022. 
 
You asked the Plan to pay for an osseous surgery and a bone replacement graft. You say that these services 
were medically necessary. 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 an 
osseous surgery (D4261), and a bone replacement graft (D4263) provided on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 provided on October 27, 2022. 
 
You asked the Plan to pay for procedure code 99213. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code 99213 is included in the global surgery 
payment for procedure code 11042 provided on October 27, 2022. Separate payment cannot be made for 
procedure code 99213. Initial consultation or evaluation of the problem by the surgeon to determine the need 
for surgery can be billed separately using modifier 57; however, this visit may be billed separately only for 
major surgical procedures. Procedure code 11042 is not considered a major surgical procedure. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99213 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99213 provided on October 27, 
2022.