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

 
We decided that the Plan does not have to pay for a surgical pathology procedure and a decalcification 
procedure provided on October 12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a surgical pathology procedure and a decalcification procedure. You say that the 
records attached support the services provided. The Plan denied your request. The Plan says services were 
obtained by an out-of-network (OON) provider and can be rendered by an in-network 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 a surgical pathology procedure and a 
decalcification procedure provided on October 12, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit; including denosumab injections provided on 
July 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services were previously authorized. 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 an office visit; including denosumab injections 
provided on July 19, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided on January 25, 2022, 
to June 21, 2022. 
 
You asked the Plan to waive the copayment for office visits. 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 $30 
copayment per visit for physician/practitioner services.  
 
You have been asked to pay a $30 copayment per visit for office visits. The total amount you are being asked 
to p ay is $180 ($30 x 6 visits = $180). This item/service falls within the physician/practitioner services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for office visits provided on January 25, 2022, to 
June 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
August 15, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. You say that you disagree with the 
cost share. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient diagnostic tests. You are 
being asked to pay $202.36 towards your $750 deductible. The item or service you asked the Plan to waive the 
copayment for falls within the outpatient diagnostic tests benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient diagnostic 
tests. This cost sharing is a contractual obligation that had not been met at the time outpatient diagnostic tests 
was received on August 15, 2022. Therefore, we decided that the Plan does not have to waive the copayment 
for outpatient diagnostic tests provided on August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood draw with travel expenses provided on June 29, 2021. 
 
You asked the Plan to pay for blood draw with travel expenses. 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 blood draw with travel 
expenses provided on June 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pulmonary rehabilitation billed under code 
94625 provided on May 03, 2022, to June 16, 2022. 
 
You asked the Plan to waive the copayment for pulmonary rehabilitation billed under code 94625. You say that 
he should not be charged for the visits, these should be covered under the health plan. 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 $10 
copayment for Pulmonary rehabilitation services. 
 
You have been asked to pay a $10 copayment for pulmonary rehabilitation billed under code 94625. This 
item/service falls within the Pulmonary 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 pulmonary rehabilitation billed under code 94625 provided on May 03, 2022, to 
June 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the five physical therapy visits provided 
from March 9, 2022, to April 27, 2022, and the MRI (magnetic resonance imaging) provided on April 29, 
2022. 
 
You asked the Plan to waive the copayments for the physical therapy visits and the MRI (magnetic resonance 
imaging). You say that you were not told that there would be copayments for these services. 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 $30 
copayment for Medicare-covered physical therapy in-person visits, and a $225 copayment for Medicare-
covered diagnostic radiology services besides mammograms and ultrasounds. 
 
You have been asked to pay a $150 copayment for the five physical therapy visits ($30 x 5 visits = $150). 
These items/services fall within the outpatient rehabilitation services benefit category. You have also been 
asked to pay a $138.67 copayment for the MRI (magnetic resonance imaging) because the allowed amount for 
this service is less than $225. This item/service falls within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the five 
physical therapy visits provided from March 9, 2022, to April 27, 2022, and the MRI (magnetic resonance 
imaging) provided on April 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ankle x-ray performed by an in-
network provider on October 11, 2022. 
 
You asked the Plan to reduce the copayment for the ankle x-ray. You say that this cost-sharing should be lower. 
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 $100 
copayment for basic radiological services, which includes x-rays, when received in an outpatient hospital 
setting. 
 
You have been asked to pay a $100 copayment for the ankle x-ray. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the 
copayment for the ankle x-ray performed by an in-network provider on October 11, 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 
September 13, 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 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 May 4th, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on September 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for x-ray services provided on September 15, 
2022. 
 
You asked the Plan to waive the cost share for x-ray services. You say that you disagree with the cost share. 
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. Your 
contract with the Plan says that there is a $1000 deductible which applies to outpatient diagnostic tests. You are 
being asked to pay $92.92 towards your $1000 deductible. The item or service you asked the Plan to waive the 
cost share for falls within the outpatient diagnostic tests benefit category. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $1000 deductible which applies to outpatient diagnostic tests. 
This cost sharing is a contractual obligation that had not been met at the time x-ray services was received on 
September 15, 2022. Therefore, we decided that the Plan does not have to waive the cost share for x-ray 
services provided on September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction and a bone replacement graft (D7140, D7953) 
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 an 
extraction and a bone replacement graft (D7140, D7953) provided on September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive and prism lenses provided on May 18, 2022. 
 
 You asked the Plan to pay for the progressive and prism lenses. You say that you got the progressive lenses 
with prisms because those were the lenses that helped. You say you would have gotten readers. The Plan 
denied your request. The Plan says the services are not covered benefits. 
 
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 only covers standard eyeglasses. 
 
We looked at the file and the Plan's rules. Specifically, the services are not covered benefits. Based on this 
information, we decided that the Plan's rules for coverage of the progressive and prism lenses have not been 
met. Therefore, we decided that the Plan does not have to pay for the progressive and prism lenses provided on 
May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided on 
May 25, 2022, to July 25, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you are disputing the 
share cost. 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 10% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 10% coinsurance for each durable medical equipment. This item/service falls 
within the durable medical equipment and related supplies benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for durable medical equipment provided on May 25, 2022, to July 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on June 23, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. 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 skilled nursing facility 
care provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 23, 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 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 31, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on September 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on September 29, 2022. 
 
You asked the Plan to pay for outpatient mental health. 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 outpatient mental health 
provided on September 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 21, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. 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 $50 
copayment for outpatient diagnostic tests/diagnostic procedures and tests, including ultrasounds.  
 
You have been asked to pay a $50 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests/diagnostic procedures and tests, including ultrasounds 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 an ultrasound provided on July 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic massage (97124). 
 
You asked the Plan to pre-approve therapeutic massage (97124). You say that you need the massages along 
with the chiropractic services so that you can breathe. You also say you have to help your wife, and you cannot 
do that if you cannot breathe. The Plan denied your request. The Plan says massage therapy when performed by 
a licensed massage therapist is not covered under any condition. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve therapeutic massage (97124).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on October 05, 2022. 
 
You asked the Plan to pay for the mental health services. You say that the records provided support medical 
necessity. 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 the mental health 
services provided on October 05, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service provided on March 02, 
2022. 
 
You asked the Plan to waive the copayment for ambulance service. You say that you are disputing the share 
cost. 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 for ambulance services. 
 
You have been asked to pay a $325 copayment for ambulance service. 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 service 
provided on March 02, 2022.