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

 
We decided that the Plan does not have to pay for laboratory service billed under coder 0334U provided on 
October 18, 2022. 
 
You asked the Plan to pay for laboratory service billed under coder 0334U. 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 service billed 
under coder 0334U provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the blood transfusion provided on April 11, 
2022. 
 
You asked the Plan to waive the copayment for the blood transfusion. You say that this service has always been 
covered. 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 $150 
copayment per visit to an outpatient hospital facility for outpatient surgery services. 
 
You have been asked to pay a $150 copayment for the blood transfusion. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 the blood transfusion provided 
on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90832) provided on June 24, 2022. 
 
You asked the Plan to pay for psychotherapy (90832). You say that due to the ongoing crisis and less amount 
of staff, it is very hard for you to work in a regular possible way. You also say it was not possible for you to get 
the authorization before the services were rendered. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy (90832) 
provided on June 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for cataract eye surgeries provided from May 
25, 2022, to June 22, 2022. 
 
You asked the Plan to waive the copayments for the cataract surgeries. You say that you were informed that 
everything would be covered. 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay a $250 copayment for each of the cataract surgeries, for a total of $500. This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 cataract 
eye surgeries provided from May 25, 2022, to June 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 30, 2022, to 
August 23, 2022. 
 
You asked the Plan to pay for the home health services. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, we find that 
the Q code line was not billed with the same revenue code and date of service correctly. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from July 30, 2022, to August 23, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for an ultrasound provided on 
September 23, 2022. 
 
You asked the Plan to waive or reduce the copayment for the ultrasound. You say that you feel the copayment 
is too high. 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 diagnostic radiology services (ultrasound).  
 
You have been asked to pay $92.06, which is less than the $100 copayment for the ultrasound. This 
item/service falls within the diagnostic radiology services (ultrasound) 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 or reduce the copayment for an ultrasound provided on September 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on May 4, 2022. 
 
You asked the Plan to pay for the durable medical equipment. 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 as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The rules say for DMEPOS claims, the place of service is the place 
where the enrollee will primarily use the DMEPOS item. In this case, the enrollee's home is the correct place of 
service. The Plan will accept a corrected claim for review. Therefore, we decided that the Plan does not have to 
pay for the durable medical equipment provided on May 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient breast cancer surgery 
provided on August 29, 2022. 
 
You asked the Plan to waive the copayment for the surgery. You say that these copayments have been 
overwhelming. 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 $250 
copayment for each Medicare-covered visit to an ambulatory surgical center or an outpatient hospital facility. 
 
You have been asked to pay a $250 copayment for the breast cancer surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 the outpatient breast cancer 
surgery provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an urgent care visit provided on August 
25, 2022. 
 
You asked the Plan to reduce the copayment for an urgent care visit. You say that you feel the copayment for 
the urgent care visit should be covered because your primary care provider did not have any openings. 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 $55 
copayment for urgently needed services. 
 
You have been asked to pay a $55 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 copayment for an urgent 
care visit provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for binaural, digital hearing aid (V5261) provided on July 22, 
2022. 
 
You asked the Plan to pay for binaural, digital hearing aid (V5261). You say that information on the Plan does 
not say anything about requirements to use the Plan hearing vendor provider for hearing aids and disagrees 
with the denial of this claim. The Plan denied your request. The Plan says the member was seen by a provider 
other than the Plan hearing vendor provider, therefore the denial is correct. 
 
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 you use a Plan hearing vendor provider and their hearing aids for this benefit.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of binaural, digital hearing aid (V5261) have not been met. Therefore, we decided that the Plan does 
not have to pay for binaural, digital hearing aid (V5261) provided on July 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
February 24, 2022, to September 2, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. 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 $65 
copayment per visit and a $250 per visit for outpatient diagnostic tests//diagnostic procedure/covered 
diagnostic radiology services.  
 
You have been asked to a $65 copayment per visit and a $250 per visit for outpatient diagnostic tests. The total 
amount you are being asked to pay for all diagnostic services is $695.83. Which is less than the required 
amount. This item/service falls within the outpatient diagnostic tests//diagnostic procedure/covered diagnostic 
radiology 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 diagnostic 
tests provided on February 24, 2022, to September 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on April 15, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that the compression stocking is medically 
necessary. The Plan denied your request. The Plan says the requested service is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
  Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on April 15, 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 your function has severely declined, and you require 
assistance to complete everyday tasks. The Plan denied your request. The Plan says you do not meet functional 
criteria for skilled nursing facility (SNF) admission for skilled therapy. 
 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have identifiable skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. However, the enrollee 
does not require daily skilled nursing or skilled therapy on an inpatient basis in a 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a monaural, digital, hearing aid (V5257) for each ear 
provided on September 29, 2022. 
 
You asked the Plan to pay for a monaural, digital, hearing aid (V5257) for each ear. You say that you are 
totally mystified by the denial since you have not used your hearing aid benefit from this Plan before your 
current request. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
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 covers a 
$1,400 allowance per ear that you can use to help pay for one hearing aid per ear every 60 months.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules say that they cover up to $1,400 allowance per ear 
every 60 months. The Plan rules also say that if the hearing aid(s) cost more than $1,400 per ear, you pay the 
difference. The record shows that this benefit was exhausted with this claim. Based on this information, we 
decided that the Plan's rules for coverage of a monaural, digital, hearing aid (V5257) for each ear have not been 
met. Therefore, we decided that the Plan does not have to pay for a monaural, digital, hearing aid (V5257) for 
each ear provided on September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral radiographic images (D0210), a cleaning (D1110), 
application of fluoride (D1206), and resin-based composite (D2332) for tooth #26 provided on July 6, 2022, 
and July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told about a dental maximum 
and would like for the dental services to be paid. The Plan denied your request. The Plan says your yearly 
dental benefit for 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 items or services was exhausted on date of service July 13, 2022. On the 
dates of service, the Plan paid $500 for the dental services. Therefore, we decided that the Plan does not have to 
pay for intraoral radiographic images (D0210), a cleaning (D1110), application of fluoride (D1206), and resin-
based composite (D2332) for tooth #26 provided on July 6, 2022, and July 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 pre-approve Dupixent.  
 
Benefits for Dupixent 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for standard frames (V2020) and spherocylinder bifocal lenses 
(V2203) provided on September 9, 2022. 
 You asked the Plan to pay for standard frames (V2020) and spherocylinder bifocal lenses (V2203). You say 
that you went to this provider on September 9, 2022. You also say that to your knowledge, your visit on 
September 9, 2022, was your yearly eye examination. The Plan denied your request. The Plan says you have 
already used this benefit. 
 
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 standard lenses and frames every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $400 allowance toward your 
purchase of frames. The Plan rules also say they cover one pair of standard lenses and frames every year. The 
record shows this benefit was exhausted on August 24, 2022. Based on this information, we decided that the 
Plan's rules for coverage of standard frames (V2020) and spherocylinder bifocal lenses (V2203) have not been 
met. Therefore, we decided that the Plan does not have to pay for standard frames (V2020) and spherocylinder 
bifocal lenses (V2203) provided on September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120) 
provided on September 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was a charge for your second oral 
evaluation which is allowed by your coverage agreement. 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 March 17, 2022. 
Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation - established patient 
(D0120) provided on September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0350 and D0150) on September 26, 
2022. 
 
You asked the Plan to pay for the dental services (D0350 and D0150). 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 
the dental service (D0150) has already been exhausted. The dental service (D0350) 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 09, 2021. 
Therefore, we decided that the Plan does not have to pay for the dental services (D0350 and D0150) on 
September 26, 2022.