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

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on September 28, 
2022. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you feel this should be covered in 
full or have a much lower 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 $100 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $100 copayment for an endoscopy. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an endoscopy provided on September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92012) 
provided on September 29, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination (92012). You say that these 
upcoming visits with a retina specialist would not have been needed if there was not a complication from 
surgery. You also say you should not have the burden of the added expense of two surgeries and added visits. 
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 Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of 
the eye. 
 
You have been asked to pay a $45 copayment for a medical eye examination (92012). This item/service falls 
within the Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the 
eye 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 a medical eye examination 
(92012) provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for acupuncture provided on September 15, 
2022. 
 
You asked the Plan to waive the copayment for acupuncture. You say that you want to appeal the amount being 
charged. 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 acupuncture (Medicare-covered) for chronic low back pain. 
 
You have been asked to pay a $40 copayment for acupuncture. This item/service falls within the acupuncture 
(Medicare-covered) for chronic low back pain 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 acupuncture provided on September 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on December 21, 2021. 
 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the transport was medically necessary therefore payable. The Plan denied your request. The Plan says the 
ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance service, basic life support, 
non-emergency transport.  Our reviewer says that the transportation via ambulance from the enrollee's doctor appointment to the enrollee's 
nursing home was not medically necessary. Our physician reviewer found the enrollee did not require the 
expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport. Transportation could have been provided by other means without endangering the enrollee's 
condition. 
 
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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the pulmonary office visit provided on 
October 4, 2022. 
 
You asked the Plan to reduce the copayment for the office visit. You say that the copayment for this service 
should be lower. 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 each covered visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $40 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors 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 reduce the copayment for the pulmonary office visit provided on October 4, 2022.
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 reconsideration because the services 
are medically necessary. 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) provided on August 24, 2022. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 We looked at the file and Medicare rules. Payment for the requested services (J3490) is included in the global 
surgery payment for the procedure (20610) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the Plan 
does not have to pay for the drugs (J3490) provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient hospital visit provided on August 30, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient hospital visit. You say that the reports attached support the services 
provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
rendered. 
 
 
 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 outpatient hospital visit provided on August 30, 
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 the outpatient hospital services provided on August 9, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The file shows the claim was billed without the G0 condition code 
which caused procedure codes G0463 and G0402 to deny. Therefore, we decided that the Plan does not have to 
pay for the outpatient hospital services provided on August 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable to be 
transferred to an LTACH level of care. You say that the enrollee would not qualify for a lower level of care due 
to being too medically complex. The Plan denied your request. The Plan says an LTACH 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 LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is improving and only requires short-term acute care at the current 
facility until they are more stable. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
   
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the removal of residual 
tooth roots (D7250) for teeth numbers 24 and 25 provided on July 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that tooth particles were left in your gums when they 
pulled your tooth on March 5, 2019. You also say you cannot afford to pay this bill with the income you get 
monthly. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 11, 2022. The 
removal of residual tooth roots (D7250) was exhausted on March 15, 2019. Therefore, we decided that the Plan 
does not have to pay for a limited oral evaluation (D0140) and the removal of residual tooth roots (D7250) for 
teeth numbers 24 and 25 provided on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a complete series 
of intraoral x-rays (D0210), two-dimensional oral/facial x-rays (D0350), a detailed and extensive oral 
evaluation (D0160), diagnostic casts (D0470), cone beam computed tomography capture (D0367), local 
anesthesia (D9215), four endosteal implants (D6010), four prefabricated abutments (D6056), five intravenous 
(IV) sedations (D9243), radiographic/surgical implant index (D6190), implant/abutment fixed mandibular 
denture (D6118) a complicated suture (D7912), two panoramic x-rays (D0330), intravenous moderate sedation 
(D9239), a complete maxillary denture (D5110), an occlusal adjustment (D9921) and nine extractions of 
erupted teeth or exposed roots (D7140) provided from May 31, 2022, to August 10, 2022. 
 
  You asked the Plan to pay for the dental services. You say that you realize the dentist is out-of-network, and 
you are seeking only reimbursement for surgery for the extractions and anesthesia. 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 a comprehensive oral evaluation (D0150), a complete series of intraoral x-rays (D0210), two-
dimensional oral/facial x-rays (D0350), a detailed and extensive oral evaluation (D0160), diagnostic casts 
(D0470), cone beam computed tomography capture (D0367), local anesthesia (D9215), four endosteal implants 
(D6010), four prefabricated abutments (D6056), five intravenous (IV) sedations (D9243), radiographic/surgical 
implant index (D6190), implant/abutment fixed mandibular denture (D6118) a complicated suture (D7912), 
two panoramic x-rays (D0330), intravenous moderate sedation (D9239), a complete maxillary denture 
(D5110), an occlusal adjustment (D9921) and nine extractions of erupted teeth or exposed roots (D7140) 
provided from May 31, 2022, to August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided on 
August 12, 2022. 
 
You asked the Plan to pay for the removal of residual tooth roots (D7250). You say that code D7140 should 
have been billed for the extraction and not code D7250. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
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 
removal of residual tooth roots (D7250) provided on August 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 11, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says there is no authorization on file for the services rendered. 
 
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 provided on October 11, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab testing on October 19, 2022. 
 
You asked the Plan to waive the deductible for lab testing. You say that you want to appeal the amount being 
charged. 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. Your 
contract with the Plan says that there is a $450 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $450 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
lab testing was received on October 19, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for lab testing on October 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home care services provided on May 11, 2022, to June 9, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health care. You say that the records attached support the services 
rendered. The Plan denied your request. The Plan says there is no authorization on file for the services 
provided. 
 
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 home care services provided on May 11, 2022, to 
June 9, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insulin injection (J1815) and self-administered drugs 
(A9270) provided from September 8, 2022, to September 10, 2022. 
 
You asked the Plan to pay for insulin injection (J1815) and self-administered drugs (A9270). You say that you 
are appealing the Plan' decision to deny your medically necessary inpatient care based on the submitted 
records. The Plan denied your request. The Plan says self-administered drugs are not covered under Medicare 
Part B. The Plan also says that they must follow Medicare rules, and the self-administered drugs requested here 
are not among the types which are covered by Medicare Part B. 
 
  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 insulin injection (J1815) and 
self-administered drugs (A9270) provided from September 8, 2022, to September 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a massage appointment provided on July 21, 2022. 
 
You asked the Plan to pay for a massage appointment. You say that you are appealing the denial for his 
fitness/wellness allowance that the Plan reimburse up to $250 per calendar year towards the cost of a 
membership for which you submitted the required information. The Plan denied your request. The Plan says 
based on the review of additional clinical information received, it was determined that massage therapy is not a 
covered benefit under the wellness allowance. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only The Plan rules say that the Plan reimburses you up to $250 per calendar year towards your cost for 
membership in a qualified health club or fitness facility during the calendar year. The record shows that a 
massage appointment is not included in this benefit. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the benefit does not cover 
membership fees you pay to non-qualified health clubs or fitness facilities, including but not limited to, martial 
arts centers; gymnastics facilities; country clubs, sports clubs and social clubs; and for sports activities such as 
golf and tennis. Therefore, we decided that the Plan does not have to pay for a massage appointment provided 
on July 21, 2022.