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

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
March 18, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider. 
 
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 when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan contract states that hearing aids should be 
purchased from the Plans select hearing aid provider. The hearing aids in this case were purchased from an 
out-of-network provider. Therefore, we decided that the Plan does not have to issue reimbursement for the 
hearing aids (V5261) purchased on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth visit provided on provided on June 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for telehealth 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 telehealth visit provided on provided on June 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422), ground 
mileage (A0425), and specialty care transport (A0434) provided on June 30, 2021. 
 
You asked the Plan to pay for the ambulance oxygen and oxygen supplies, ground mileage, and specialty care 
transport. You say that the hospital should not be held liable when the patient has not presented insurance 
accurately or timely. You also say that the Facility delivered valuable goods and services to the enrollee, and 
deserves to be paid for those goods and services. The Plan denied your request. The Plan says the time limit for 
filing has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance oxygen and oxygen supplies, ground mileage, and specialty 
care transport was not filed until August 16, 2022. This means that more than one calendar year from the date 
of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the 
ambulance oxygen and oxygen supplies (A0422), ground mileage (A0425), and specialty care transport 
(A0434) provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on August 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a specialist visit. You say that neither you nor the patient knew you needed 
preauthorization for this service, and it was medically necessary. The Plan denied your request. The Plan says 
there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network 
(OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 specialist visit provided on August 2, 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 May 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you thought the provider was in-network. 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 May 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88305, 88312) provided on June 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory 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 were 
non-emergent and prior authorization was not 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 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 services (88305, 88312) provided on 
June 16, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay (R0120) provided on 
October 18, 2021 to October 21, 2021 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered as you disagree with the charges. 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 $390 
copayment per day for days 1-5 of Inpatient hospital care.  
 
 
  You have been asked to pay a $1,170 copayment for 3 days of inpatient hospital care. This item/service 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 (R0120) provided on October 18, 2021 to October 21, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aid, digital, binaural, behind the ear (V5261), hearing 
aid or assistive listening device/supplies/accessories, not otherwise specified (V5267), and dispensing fee 
(V5160) provided on July 6, 2022. 
 
You asked the Plan to pay for the hearing aids, accessories and dispensing fee. You say that this provider was 
the most convenient to provider your hearing aids. The Plan denied your request. The Plan says hearing aid 
services must be registered in advance. 
 
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 when you obtain prior authorization. 
 
We looked at the file and the Plan's rules. In this case you did not contact the Plans hearing aid vendor to get 
prior authorization to obtain hearing aids from a network provider. Based on this information, we decided that 
the Plan's rules for coverage of the hearing aids, accessories and dispensing fee have not been met. Therefore, 
we decided that the Plan does not have to pay for hearing aid, digital, binaural, behind the ear (V5261), hearing aid or assistive listening device/supplies/accessories, not otherwise specified (V5267), and dispensing fee 
(V5160) provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on February 10, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a specialist visit. You say that service is needed based on medical necessity and 
is asking the plan to reconsider payment. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 specialist visit provided on February 10, 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 a chiropractic treatment provided on July 13, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the chiropractic treatment. You say that this service should be covered because 
this chiropractor is helping with your hip pain. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. There are participating providers available in your area that are accepting new 
patients covered by the Plan. 
 
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 chiropractic treatment provided on July 13, 
2022, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on April 19, 2022, and 
April 20, 2022. 
 
You asked the Plan to pay for the drugs. You say that you don't feel that you owe these pharmacy charges. The 
Plan denied your request. The Plan says this is not a covered 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 pay for self-administered drugs received 
on April 19, 2022, and April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring services provided on February 19, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON remote monitoring services. You say that remote monitoring is 
medically necessary for this patient. Due to the nature of this service, the Plan should pay this claim. The Plan 
denied your request. The Plan says unauthorized, out-of-network services are not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The provider in this case is not a network provider with the Plan. 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 remote monitoring services provided on February 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 coinsurance for an annual wellness visit provided on May 
2, 2022. 
 
You asked the Plan to waive the coinsurance for an annual wellness visit. You say that you do not agree 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% 
coinsurance for annual wellness visit.  
 
You have been asked to pay a 50% coinsurance for an annual wellness visit. The total allowed amount you are 
being asked to pay is $148.82. You are being asked to pay $74.41 ($148.82 + 50% = $74.41). 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 annual wellness visit provided on May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on March 28, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for wound care supplies. 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 wound care supplies provided on March 28, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services (90837) provided on August 12, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mental health 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 were 
non-emergent and prior authorization was not 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 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 mental health services (90837) provided on 
August 12, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for selective catheter placement and angiography (procedure 
codes 36245 and 75710) provided to the enrollee on January 29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 36245: 
 
Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery 
branch, within a vascular family 
 
CPT 75710: 
 Angiography, extremity, unilateral, radiological supervision and interpretation 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 36245, this codes 
for arterial access with selective first-degree catheterization, a procedure typically performed during the 
conduct of arteriography. There is no documentation that this was performed. Similarly, CPT 75710 codes for 
supervision and interpretation of an extremity angiogram; there is no documentation that this was performed. 
The denied codes were not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for selective catheter placement and angiography (procedure codes 36245 and 75710) provided to 
the enrollee on January 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 19, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for colostomy supplies provided from 
November 27, 2021, to August 4, 2022. 
 
You asked the Plan to waive the coinsurance for the colostomy supplies. You say that you were informed you 
no longer had to pay the coinsurance. 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 20% 
coinsurance for prosthetic devices and related supplies.  
 
You have been asked to pay a 20% coinsurance for the colostomy supplies. This item/service falls within the 
prosthetic devices 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 
colostomy supplies provided from November 27, 2021, to August 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on 
June 15, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you are a breast 
cancer survivor, and the test should 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 $35 
copayment for x-ray services. 
 
You have been asked to pay a $35 copayment for the diagnostic mammogram. This item/service falls within 
the x-ray 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 the diagnostic 
mammogram provided on June 15, 2022.