Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service (D9310) provided on 
January 20, 2022. 
 
You asked the Plan to pay for the consultation. You say that you would like a copy of the guidelines used to 
make the decision to deny the claim. The Plan denied your request. The Plan says the service provided is not a 
covered benefit under your dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation - diagnostic service (D9310) provided on January 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from June 
15, 2021, to June 18, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were told there would 
be no cost to you. 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 $395 
copayment each day for days 1 to 5 for Medicare-covered hospital care. $0 copayment for additional Medicare-
covered days.  
 
 
 
 You have been asked to pay $1,185 ($395 x 3 days) copayment for inpatient hospital stay. Inpatient hospital 
stay 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 inpatient hospital stay provided from June 15, 2021, to June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network, and it was determined these services 
can be received in-network. 
 
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 provided on February 15, 2022, by 
an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room visit (99285) provided on January 19, 
2022. 
 
You asked the Plan to pay for procedure code 99285. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 9, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 99285 have not been met. 
Therefore, we decided that the Plan does not have to pay for the emergency room visit (99285) provided on 
January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for oxygen equipment provided on February 
18, 2022. 
 
You asked the Plan to waive the copayment for oxygen equipment. You say that you didn't use the equipment 
so you shouldn't be charged. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for all other covered DME items.  
 
You have been asked to pay $17.78 which is 20% of the allowed amount for oxygen equipment. The allowed 
amount is $88.89 (20% x $88.89= $17.78). Oxygen equipment falls within the Durable Medical Equipment 
(DME) 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 copayment for oxygen 
equipment provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist visit provided on April 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for specialist visit. You say that you should only have to pay your normal specialist 
copayment. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advanced. 
 
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 specialist visit provided on April 19, 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 provided on March 9, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the services 
rendered on March 9, 2022. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
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 provided on March 9, 2022, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory tests must be billed with a unique test 
identifier.  
 We looked at the file and Medicare rules. Review of the file shows that no unique test identifier was billed on 
the claim. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out of network specialist office visit and an 
infusion provided on January 27, 2022. 
 
You asked the Plan to waive the copayment for out of network specialist office visit and an infusion. You say 
that that the provider was in network. 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 $25 
copayment for out of network specialist office visits and 20% coinsurance for Medicare covered drugs.   
 
 
You have been asked to pay a total of $25.36 ($25 office visit) copayment for out of network specialist office 
visit and infusion. You have been asked to pay .36 cents which is 20% of the allowed amount for the infusion. 
The allowed amount is $1,80(20% x $1.80= .36 cents). Specialist office visits fall within the Physician/ 
Practitioner Services, Including Doctor's Office Visits benefit category. Infusions fall 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 copayment for out of 
network specialist office visit and an infusion provided on January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory procedures provided on March 24, 2022, by an 
OON provider. 
 
You asked the Plan to pay for laboratory procedures. You say that the doctor's office failed to send in a 
preauthorization for approval. The Plan denied your request. The Plan says the out-of-network services were 
not authorized. 
 
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 laboratory procedures provided on March 24, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on February 1, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on April 1, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should only be charged the $30 
copayment for the office visit. 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 $125 
copayment for Medicare covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility.  
 
You have been asked to pay $86.13 which is less than the standard $125 copayment for an ultrasound. 
Ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Serviced 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 ultrasound provided on April 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for mammogram provided on May 19, 2022. 
 
You asked the Plan to waive the coinsurance for mammogram. You say that this should be covered. The Plan 
denied your request. The Plan says the coinsurance 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 20% of 
the cost for diagnostic procedures and tests.  
 
You have been asked to pay $40.11 which is 20% of the allowed amount for mammogram. Mammograms 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 coinsurance for mammogram provided on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on December 30, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 hospital outpatient clinic visit provided on 
December 30, 2020, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for ophthalmic diagnostic imaging provided 
on March 8, 2022. 
 
You asked the Plan to reduce the copayment for ophthalmic diagnostic imaging. You say that this should only 
be $15 copayment for the routine eye exam. 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 $35 
copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 
 
 You have been asked to pay $35 copayment for ophthalmic diagnostic imaging. Ophthalmic diagnostic 
imaging falls within the Vision 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 reduce the copayment for 
ophthalmic diagnostic imaging provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310), a periapical x-ray (D0220), 
endodontic therapy on tooth #12 (D3320), and a prefabricated post on tooth #12 (D2954) provided on 
September 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that if you would have known the truth about your 
benefits you would have postponed your visit. The Plan denied your request. The Plan says a consultation 
(D9310), a periapical x-ray (D0220), endodontic therapy (D3320), and a prefabricated post (D2954) are not 
covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310), a periapical x-ray (D0220), endodontic therapy on tooth #12 (D3320), and a 
prefabricated post on tooth #12 (D2954) provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and biopsy provided on April 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and biopsy. You say that the visit was not an emergency, but it 
was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
office visit and the biopsy. We found no exception that would require the Plan to pay for the office visit and the 
biopsy. The records provided for review do not show that the services at issue were urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for the office visit and biopsy provided on April 7, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sleep apnea device provided on December 8, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for sleep apnea device. You say that the item provided was medically necessary. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
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 sleep apnea device provided on December 8, 
2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy office visit provided on January 21, 2022, 
by an OON provider. 
 
You asked the Plan to pay for a psychotherapy office visit. You say that you are requesting reconsideration and 
have submitted medical records for medical necessity. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 psychotherapy office visit provided on January 
21, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for at-home COVID-19 tests purchased on January 
25, 2022. 
 
You asked the Plan to reimburse you for at-home COVID-19 tests. You say that you purchased the tests only a 
few days before the benefit went into effect. You say you would like to be reimbursed for your purchase. The 
Plan denied your request. The Plan says the decision to deny reimbursement for the COVID-19 home test kits 
was correct. 
 
The Plan must follow Medicare rules. The rules say that health plans were given the option to cover COVID-19 
home testing kits as a supplemental benefit but were not required to do so by Medicare. The Plan 
communicated to enrollees that this testing would be covered as a supplemental benefit, free of charge, after 
February 1, 2022. Furthermore, Medicare began providing coverage of COVID-19 home testing kits starting on 
April 4, 2022. Your purchase was made prior to both of these dates. Therefore, we decided that the Plan does 
not have to reimburse you for at-home COVID-19 tests purchased on January 25, 2022.