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

 
We decided that the Plan does not have to pay for laboratory testing provided on August 27, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and should be 
covered. 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 laboratory testing 
provided on August 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 15, 2022. 
 
You asked the Plan to pay for home health services. 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 home health services 
provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an out of area referral. 
 
You asked the Plan to pre-approve an out of area referral. You say that the requested out of area referral for 
Avastin injections is medically necessary. The Plan denied your request. The Plan says that the requested out of 
area referral for Avastin injections is not medically necessary. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 an out of area referral. Our reviewer 
says that the requested out of area referral for Avastin injections is medically necessary. Our physician 
reviewer found while it was foreseen that the enrollee will need his upcoming maintenance eye injections, the 
enrollee is going to be out of the Plan's service area for a certain amount of time. The care requested is 
medically necessary. Active macular degeneration often needs serial anti-VEGF (such as Avastin) to remain 
stable; otherwise, it will cause acute inflammation and bleeding leading to permanent loss of vision. This 
enrollee has been receiving injections every 4 weeks to maintain his eye condition and his physician stated the 
longest he could extend it is 5-6 weeks before signs and symptoms would develop. His last eye injection was 
January 31, 2023. The enrollee had plans to go to Florida for an extended period of time that does not allow 
him to return in time for this needed maintenance dose of eye injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an out of area referral have been met. Therefore, we decided that the Plan has to 
pre-approve an out of area referral for Avastin injections.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring treatment provided on 
September 30, 2022. 
 
You asked the Plan to pay for remote physiologic monitoring treatment. 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 remote physiologic 
monitoring treatment provided on September 30, 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 just had total knee replacement on left knee and 
need care. You state that you are home alone, and you need to be taking medication every 4 hours for pain. 
You need assistance getting out of bed and going to the bathroom. The Plan denied your request. The Plan says 
this 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 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 skilled nursing facility (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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on March 29, 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 March 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance provided on April 16, 2022, to October 24, 2022. 
 
You asked the Plan to pay for ambulance. 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 ambulance provided on 
April 16, 2022, to October 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for all services rendered from January 6, 2022, to August 4, 
2022. provided on January 06, 2022, to August 04, 2022. 
 
You asked the Plan to pay for all services rendered from January 6, 2022, to August 4, 2022.. You say that you 
were incapable of dealing with this and your out-of-network status continued. 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 all services rendered 
from January 6, 2022, to August 4, 2022. provided on January 06, 2022, to August 04, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post-stabilization services provided from July 14, 2022, 
to July 15, 2022. 
 
You asked the Plan to pay for the post-stabilization services. You say that the post stabilization services 
provided by the non-contracted provider were medically necessary. The Plan denied your request. The Plan 
says the post stabilization services provided by the non-contracted provider were not medically necessary. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization services. Our reviewer 
says that the post stabilization services provided by the non-contracted provider were not medically necessary. 
Our physician reviewer found there was no documentation provided indicating medical necessity for post-
stabilization care services after the emergency department evaluation on July 14, 2022. The enrollee was 
hemodynamically stable for ambulance transport with monitoring to a Plan facility for observation/admission 
level of care services. The post-stabilization care services were not medically necessary or reasonable. The 
review has determined that the treating physician did not document (in the physician notes, on a form, or in an 
order) that the enrollee was not stable for transfer on any dates of service. 
 
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 post-stabilization services have not been met. Therefore, we decided that the 
Plan does not have to pay for the post-stabilization services provided from July 14, 2022, to July 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on October 21, 2022. 
 
You asked the Plan to pay for wound 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 wound care provided on 
October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on November 
4, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you did not receive services 
from a specialist. 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 the specialist visit. This item/service falls within the 
physician/practitioner services, including doctor's 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 the specialist visit provided on November 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the neurostimulator device provided on 
September 14, 2022. 
 
You asked the Plan to reduce the coinsurance for the neurostimulator device. You say that you want to make 
sure these services were charged correctly. 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 in-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the neurostimulator device. This item/service falls within the 
in-network durable medical equipment 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. However, due to meeting your annual out-of-
pocket maximum, you are only being charged $2,832.85 which is less than the standard 20% coinsurance. 
Therefore, we decided that the Plan does not have to reduce the coinsurance for the neurostimulator device 
provided on September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 12, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. 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 laboratory services 
provided on October 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the liver biopsy provided on September 02, 
2022. 
 
You asked the Plan to waive the copayment for the liver biopsy. You say that you cannot afford this copayment 
due to previous medical bills. 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 $250 
copayment for in-network outpatient surgery at an outpatient hospital facility. 
 
You have been asked to pay a $250 copayment for the liver biopsy. This item/service falls within the in-
network outpatient surgery at an outpatient hospital facility 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 liver biopsy provided on September 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation and cleaning (D0120, 
D1110) provided on November 15, 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Coverage for the periodic oral evaluation was 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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Coverage for the periodic oral evaluation was exhausted on March 21, 2022, and April 26, 2022. Therefore, we 
decided that the Plan does not have to pay more for a periodic oral evaluation and cleaning (D0120, D1110) 
provided on November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Comprehensive Oral Evaluation, Intraoral x-ray, filling, 
cleaning, core buildup services, crown, and Unspecified Preventative Procedure (D0150, D0210, D2392, 
D1110, D2950, D2750, D1999) provided on October 27, 2022, to November 2, 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. Coverage for the crown and Unspecified 
Preventative Procedure 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. 
 
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, Intraoral x-ray, filling, cleaning, core buildup services, crown, 
and Unspecified Preventative Procedure (D0150, D0210, D2392, D1110, D2950, D2750, D1999) provided on 
October 27, 2022, to November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on January 
06, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you have no copayments 
for lab services 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 $10 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls within the in-
network outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the laboratory services provided on January 06, 2023.