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

 
We decided that the Plan does not have to waive the copayment for ambulance Services provided on July 1, 
2022. 
 
You asked the Plan to waive the copayment for ambulance Services. You say that you disagree 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for ambulance Services.  
 
The enrollee has been asked to pay a $250 copayment for ambulance Services. This item/service falls within 
the ambulance Services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance Services provided on July 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits January 4, 2022, to 
July 19, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that you disagree with 
copayments. 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 $30 
copayment per visit for physician/practitioner services.  
 
You have been asked to pay a $30 copayment per visit for specialist office visits. The total allowed amount for 
the office visits is $450 ($30 x 15visits = $450). However, you are being asked to pay is $435 which is less 
than the required amount. This item/service falls within the physician/practitioner 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 specialist office visits January 4, 2022, to July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a podiatry visit provided on July 16, 2019, to August 07, 
2019. 
 
You asked the Plan to pay for a podiatry visit. You say that you looked at the plan website and saw this 
provider listed as in-network. 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 a podiatry visit provided 
on July 16, 2019, to August 07, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug (A9270) provided on  
September 12, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item 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 drug provided is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug 
(A9270) provided on September 12, 2022.  
 Benefits for this item may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 21, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. 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 office visit provided on 
September 21, 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) for tooth #3 and 
#4 provided on August 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
the removal of residual tooth roots is not covered by the 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 the 
removal of residual tooth roots (D7250) for tooth #3 and #4 provided on August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodontal maintenance procedure (D4910) provided 
on August 29, 2022. 
 
You asked the Plan to pay more 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 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.    
 
You have been asked to pay a $575 deductible for dental services provided by an out-of-network provider. This 
item/service falls within the dental 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 pay more for a periodontal maintenance procedure 
(D4910) provided on August 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on September 12, 2022, 
to September 16, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. 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 skilled nursing facility 
care provided on September 12, 2022, to September 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64633-RT, 64633-LT, 64634-RT, and 
64634-LT billed for date of service March 2, 2022. 
 
You asked the Plan to pay for procedure codes 64633-RT, 64633-LT, 64634-RT, and 64634-LT. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64633 is 
1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Furthermore, CPT 
code 64634 is an add-on code and as the primary code, 64633, is not payable, the add-on code cannot be paid 
separately. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 64633-RT, 64633-
LT, 64634-RT, and 64634-LT have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 64633-RT, 64633-LT, 64634-RT, and 64634-LT billed for date of service March 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on July 11, 2022. 
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration. 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 x-rays provided on July 
11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999) provided on 
April 29, 2022. 
 
You asked the Plan to pay for an unspecified adjunctive procedure. You say that you would like the Plan to pay 
for this. The Plan denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified adjunctive procedure (D9999) provided on April 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport, level 1 provided on May 8, 2022. 
 
You asked the Plan to pay for the ambulance service, advanced life support, emergency transport, level 1. You 
say that you had to be transported to a hospital that was unable to treat your condition to perform an emergency 
angiogram. The Plan denied your request. The Plan says they have reached out to the other insurance provider 
and provided the details and date of service. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed the 
provider to submit this claim to your primary insurance carrier. As the secondary insurer, the Plan cannot be 
held responsible for the ambulance service, advanced life support, emergency transport, level 1 until the 
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to 
pay for the ambulance service, advanced life support, emergency transport, level 1 provided on May 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration services and a surgical placement 
of implant body (D4267, D6010) provided on September 6, 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 guided tissue regeneration services and a surgical placement of implant body (D4267, D6010) 
provided on September 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on February 24, 2022. 
 
You asked the Plan to pay for injections. You say that you are appealing with supporting records. 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 injections provided on 
February 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound screening exam of abdominal aorta (76706) 
provided on August 12, 2022. 
 
  You asked the Plan to pay for the ultrasound screening exam of abdominal aorta. You say that this procedure 
was performed at the request of the referring doctor, as the enrollee's medical condition proved the medical 
necessity for this service. The Plan denied your request. The Plan says this was billed with diagnosis codes 
Z13.6, defined as Encounter for screening for cardiovascular disorders, which is not considered as appropriate 
diagnosis code for an ultrasound screening exam of abdominal aorta as per the above guidelines. The Plan also 
says the documentation does not show that the enrollee received the screening study for one of the risk 
categories as listed in the guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for AAA for beneficiaries who meet the criteria listed in the Medicare rules section of this letter.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ultrasound screening exam of abdominal aorta have not been met. Therefore, we decided that 
the Plan does not have to pay for the ultrasound screening exam of abdominal aorta (76706) provided on 
August 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on July 23, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you feel you should have a $50 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 $175 
copayment for outpatient diagnostic tests/Medicare-covered outpatient diagnostic.  
 
You have been asked to pay a $175 copayment for MRI. This item/service falls within the outpatient diagnostic 
tests/Medicare-covered outpatient diagnostic 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 magnetic resonance imaging (MRI) provided on July 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis provided on June 01, 2022, to 
June 03, 2022. 
 
You asked the Plan to waive the coinsurance for dialysis. 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 20% 
coinsurance for services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for dialysis. This item/service falls within the services to treat 
kidney disease 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 dialysis provided on June 
01, 2022, to June 03, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 26, 
2022, to July 2, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree 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 $298 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $298 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay is $1,490 ($298 x 5days =$1,490). 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 care provided on June 26, 2022, to July 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on June 28, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that we depend on the facility staff to verify 
eligibility and to obtain authorization. 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 a nursing facility visit 
provided on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on July 25, 2022, from 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were advised that you could go in-network 
and out-of-network for hearing aids. The Plan denied your request. The Plan says hearing aids purchased from 
providers that are not Plan-approved are not covered. The Plan also says there is no record that you reached out 
to the Plan's hearing department to schedule an appointment with the provider and/or get a referral for the 
service. 
 
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 use the Plan's approved hearing aid vendor for your hearing aid benefits. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5298) purchased on July 25, 2022, from an out-of-network (OON) provider.