Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visits (99335, 99336) provided 
from September 28, 2021, to November 4, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visits. You say that the providers who visited your mom 
at the temporary facility were not in the network for her Plan. You also say you did not know they were not 
part of the network, and that your mom had no choice but to see these providers. The Plan denied your request. 
The Plan says these providers are not network providers with the Plan, and they needed an approved referral 
from the enrollee's primary care physician. The Plan also says that they have also determined that these 
services were not urgent or emergent, nor were they approved in advance. 
 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 domiciliary or rest home visits (99335, 99336) 
provided from September 28, 2021, to November 4, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injections provided on November 8, 
2021. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you were told you only had to pay 
the coinsurance for the first two injections of the year. The Plan denied your request. The Plan says the proper 
coinsurance was applied for the service rendered. 
 
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 20% 
coinsurance for each Medicare-covered Part B drug. The total amount allowed was $2,260.20 with a 
coinsurance of $452.02 ($2,260.20 total amount x 20% coinsurance). 
 
  You have been asked to pay $452.02 coinsurance for the injections. The injections falls within the Medicare 
Part B prescription drugs 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 the 
injections provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 99053 provided on July 22, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the claim has not been billed as required by 
Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. 

We looked at the file and Medicare rules. In this case, code 99053 has a Status Code of "B" under the Physician Fee Schedule. This means that payment for covered services will always be bundled into payment for 
other services not specified. Based on this information, we decided that Medicare rules for coverage of the 
medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical 
services coded 99053 provided on July 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospitalization from 
December 27, 2020, to December 30, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospitalization. You say that you thought the fees 
were waived. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $75 
copayment per day for days 1 through 5 for Medicare-covered stays at a network hospital.  
 
 
 You have been asked to pay a $75 copayment for the inpatient hospitalization. You were there for three days 
but are only getting charged the copay for one day. The inpatient hospitalization falls within the Inpatient 
hospital 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 the inpatient 
hospitalization from December 27, 2020, to December 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5mg tablets. 
 
You asked the Plan to pre-approve Eliquis. You say that Eliquis is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Eliquis 5mg tablets.  
 
 
 Benefits for Eliquis 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 the unspecified removable prosthodontic procedure, by 
report (D5899) provided November 4, 2021. 
 
You asked the Plan to pay for the unspecified removable prosthodontic procedure. You say that you were 
unaware that this was a non-participating provider. The Plan denied your request. The Plan says this claim has 
been reprocessed to be covered in-network, however this service is not covered under your 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 
unspecified removable prosthodontic procedure, by report (D5899) provided November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310), provided on October 5, 2021. 
 
You asked the Plan to pay for the consultation. You say that the service should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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. Specifically, this service is not listed in the Plan's benefit chart. This 
means the service is not covered. Therefore, we decided that the Plan does not have to pay for the consultation 
(D9310), provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) provided by a participating 
provider on April 15, 2021. 
 
You asked the Plan to pay for an endosteal implant. You say that you fell and broke your teeth on a steel bar. 
You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says D6010 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 an 
endosteal implant (D6010) provided by a participating provider on April 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiography (93306) provided on 
September 17, 2021, and September 20, 2021. 
 
You asked the Plan to waive the copayment for the echocardiography. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $155 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 You have been asked to pay a $310 copayment for two echocardiographys. Echocardiographys fall 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 copayment for an echocardiography (93306) provided on September 17, 2021, and September 20, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy visit provided on November 19, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy visit. You say that service was provided to the enrollee out 
of medical necessity. The Plan denied your request. The Plan says the rendering provider is an out-of-network 
provider and there was no approved authorization. 
  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a physical therapy visit provided on November 19, 
2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four additional home health visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says additional home health services are not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 the additional visits. Our reviewer says 
that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found 
that in this case, the documentation doesnt support that the enrollee requires additional skilled nursing 
services  to provide treatment that is medically necessary. The enrollee does not require additional skilled 
nursing services to effectively provide treatment, care, and/or services in order to improve the enrollee's 
condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
The enrollee has been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four additional home health visits for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) 
provided November 29, 2021. 
 
You asked the Plan to pay for the periodic oral exam. You say that this exam was incorrectly denied. The Plan 
denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the periodic 
oral exam twice per year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that oral exams were 
previously covered on March 29, 2021, June 3, 2021, and August 10, 2021. Based on this information, we 
decided that the Plan's frequency limit for coverage of the periodic oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) 
provided November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an arthroplasty (27447) provided from 
October 26, 2021, to October 29, 2021. 
 
You asked the Plan to waive the coinsurance for the arthroplasty. You say that the services should be covered. 
The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 25% 
coinsurance for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 You have been asked to pay a 25% coinsurance for an arthroplasty (allowed is $14,931.15 x 25% = $3,732.79). 
Arthroplastys fall 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 coinsurance for 
an arthroplasty (27447) provided from October 26, 2021, to October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urinalysis. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical documentation showing that the doctor ordered this urinalysis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the enrollee underwent a urine analysis. The records provided are insufficient to 
establish the medical necessity of the requested services. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve urinalysis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incisional biopsy (D7286) provided by a participating 
provider on November 2, 2021. 
 
You asked the Plan to pay for an incisional biopsy. You say that you disagree with this being denied. The Plan 
denied your request. The Plan says D7286 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 an 
incisional biopsy (D7286) provided by a participating provider on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
by a participating provider on April 1, 2021. 
 
You asked the Plan to pay for a comprehensive periodontal evaluation. You say that you would like the Plan to 
reimburse you for this. The Plan denied your request. The Plan says D0180 is not a covered dental 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 a 
comprehensive periodontal evaluation (D0180) provided by a participating provider on April 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 6 additional units of code A0425 (ground mileage) provided 
on November 6, 2021. 
 
You asked the Plan to pay for 6 additional units of code A0425. 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 the actual number of units 
provided for each procedure code. 
 
We find that 256 units of CPT code A0425 are not supported in the medical record. The medical record only supports 250 units of CPT code A0425. Based on this information, we decided that Medicare rules for coverage 
of 6 additional units of code A0425 have not been met. The Plan has overturned their denial of payment for 250 
units of code A0425. Therefore, we decided that the Plan does not have to pay for 6 additional units of code 
A0425 (ground mileage) provided on November 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation - 
new or established patient (D0150), bitewings - four radiographic images (D0274) and prophylaxis - adult 
(D1110) provided August 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the comprehensive oral exam, bitewing x-rays, and 
dental cleaning. You say that your benefits show that OON cost-sharing is the same as in-network. The Plan 
denied your request. The Plan says the cost sharing was applied correctly to the OON services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan contract states that if 
you choose to see an OON dentist, you might be billed for charges above what the Plan pays, even for services listed as $0 copayment. 
 
We looked at the file and Medicare rules. The requested provider in this case is OON. The Plan provided 
documentation showing that the full allowed amount was covered for each of the services. Therefore, we 
decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation - new 
or established patient (D0150), bitewings - four radiographic images (D0274) and prophylaxis - adult (D1110) 
provided August 9, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a physician office visit (99214) and an 
ophthalmic biometry procedure (92136) provided on October 20 to November 2, 2021, by an out-of-network 
provider. 
 
You asked the Plan to waive the deductible for a physician office visit and an ophthalmic biometry procedure. 
You say that you had been informed that the provider at issue was in-network. The Plan denied your request. 
The Plan says the correct cost-sharing was applied. 
 
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 $1,750 deductible which applies to Medicare-covered vision exam 
services and covered eyeglasses or contact lenses after cataract surgery when obtained from an out-of-network 
provider.   

The item or service you asked the Plan to waive the deductible for falls within the "Vision care" benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,750 
deductible which applies to Medicare-covered vision exam services and covered eyeglasses or contact lenses 
after cataract surgery when obtained from an out-of-network provider. This cost sharing is a contractual 
obligation that had not been met at the time a physician office visit and an ophthalmic biometry procedure were 
received on October 20 to November 2, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for a physician office visit (99214) and an ophthalmic biometry procedure (92136) provided on 
October 20 to November 2, 2021, by an out-of-network provider.  
 
Your complaint about receiving erroneous or incomplete information from a representative of the Plan about 
the network status of your provider is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.