Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation of oral and pharyngeal swallowing function 
(92610) rendered by the out-of-network (OON) provider on August 9, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out-of-network 
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the evaluation of oral and pharyngeal swallowing function (92610) rendered by the 
out-of-network (OON) provider on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tooth extraction (D7210) provided on April 20, 2022. 
 
You asked the Plan to pay for the tooth extraction. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a tooth 
extraction (D7210) provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
September 24, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this 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 $40 
copayment for Specialist office visits. 
 
You have been asked to pay a $40 copayment for specialist office visit. This item/service falls within the 
Specialist office visits 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 specialist 
office visit provided on September 24, 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 
27, 2022. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that you went to urgent care and 
were informed that your copayment was only $10. 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 for urgently needed services.  
 
You have been asked to pay $35, which is less than the $65 copayment for the 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 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on November 9, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that the ambulance response was necessary but 
a trip to the hospital was not. The Plan denied your request. The Plan says this service is not covered when 
there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on November 9, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D6010, D0220, D7953, D7210) provided on 
June 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services (D6010, D0220, D7953, D7210) provided on June 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for hymovis injections provided from 
December 28, 2021, to January 11, 2022. 
 
You asked the Plan to waive the coinsurance for the hymovis injections. You say that the services were 
approved and 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
  You have been asked to pay $92.45, which is 20% coinsurance for each of the two hymovis injections ($462.24 
allowed amount x 20% = $92.45). The total for both injections is $184.90. This item/service 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 
hymovis injections provided from December 28, 2021, to January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 15, 2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pay for the evaluation and management service as part of a clinical trial. The 
Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan 
does not have to pay for the office visit provided on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visits provided from August 22, 
2022, to September 12, 2022. 
 
You asked the Plan to waive the copayments for the office visits. You say that you were unaware of the 
copayments and cannot afford them. 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 $45 
copayment for physician/practitioner services, including doctor's office visits (specialist).  
 
 
  You have been asked to pay a $45 copayment for each of the two office visits, for a total of $90. This 
item/service falls within the physician/practitioner services, including doctor's office visits (specialist) 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 office visits provided from August 22, 2022, 
to September 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on August 
11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you want the Plan to pay for the 
service. The Plan denied your request. The Plan says the 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 subsequent nursing facility care (99308) provided 
on August 11, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like to stay at the facility because you 
condition is still not well. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary. 
 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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/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 SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an air ambulance transport. 
 
You asked the Plan to pay for the air ambulance transport. You say that this was an emergency air ambulance 
transport and our claim was filed as soon as the insurance information was made available to us. The Plan 
denied your request. The Plan says the claim was not received within the allowed 12 months from the date of 
service. 
 
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 air ambulance transport was not filed until August 10, 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 an air ambulance transport.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires and IRF due to the decline in 
their overall functional mobility status. You say that the enrollee continues to require physician oversight for 
their medical needs as well as extensive physician and occupational therapies for deficits including bed 
mobility, bathroom mobility, transfers, gait, standing balance, strength, and endurance. You say that the 
enrollee is requiring higher level of rehab services to optimize their mobility and strength for their return home 
with a safe and sustainable discharge. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is medically stable and does not require close supervision for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee 
can benefit from physical and occupational therapy, their needs can be safely met in an alternate and low 
intensity setting such as in home with services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on May 14, 2022, to May 
17, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you cannot afford this charge. 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for ER visit. This item/service falls within the Emergency 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 ER visit provided on May 14, 
2022, to May 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's health is not as good. You say that the 
enrollee has more health issues such as kidney and heart issues. The Plan denied your request. The Plan says an 
IRF admission is not medically necessary, and the enrollee can get the services they need provided safely in 
other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is medically stable and does not require close supervision for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee 
can benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of 
care such as in home with services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on 
August 26, 2022. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that you shouldnt have to 
pay for this. 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 $295 
copayment for Outpatient surgery in an ambulatory surgical center. 
 
You have been asked to pay a $295 copayment for diagnostic colonoscopy. This item/service falls within the 
Outpatient surgery in an ambulatory surgical center 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. You have been asked to pay $250.33 which is less than the 
standard $295 copayment for outpatient surgery. Therefore, we decided that the Plan does not have to waive 
the copayment for diagnostic colonoscopy provided on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and 
extractions (D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve an evaluation and extractions. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the requested services are not covered when performed 
by an oral surgeon. 
 
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 when performed by an oral surgeon. Therefore, we decided that the 
Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and extractions (D7210) to be 
provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on September 15, 2022. 
 You asked the Plan to pay for a specialist office visit. You say that you had routine vision care examination 
with a provider that is contract for Medicare services, but not with the Plan specific vision care network. The 
Plan denied your request. The Plan says this provider is not in network for the Plan specific vision care 
network. 
 
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 these services when a referral has been obtained from the primary care physician 
(PCP), and if you use a Plan specific vision care network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that before you receive services from an 
ophthalmologist for diagnosis and/or treatment of a medical condition of the eye, you must first obtain a 
referral from your PCP. The Plan rules also say that no referral is required to see an optometrist, but you must 
use a provider in the Plan specific vision care network. Based on this information, we decided that the Plan's 
rules for coverage of a specialist office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for a specialist office visit provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 28, 2022. 
 
You asked the Plan to pay for an office visit. You say that the Plan told you that this provider was in network, 
but they werent. You feel the plan should cover this. 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 an office visit provided 
on July 28, 2022.