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

 
We decided that the Plan does not have to pay for occupational therapy visits provided on August 22, 2022, to 
August 31, 2022. 
 
You asked the Plan to pay for occupational therapy visits. 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 occupational therapy 
visits provided on August 22, 2022, to August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an out of network office visit provided on 
March 29, 2022. 
 
You asked the Plan to waive the deductible for an out of network 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. Your 
contract with the Plan says that there is $750 deductible which applies to Physician/Practitioner services, 
including doctors office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to Physician/Practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time an 
out of network office visit was received on March 29, 2022. Therefore, we decided that the Plan does not have 
to waive the deductible for an out of network office visit provided on March 29, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy visits provided on December 14, 2021, to 
December 27, 2021. 
 
You asked the Plan to pay for physical therapy visits. 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 physical therapy visits 
provided on December 14, 2021, to December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for out of network office visits provided from 
March 24, 2022, to March 31, 2022. 
 
You asked the Plan to waive the deductible for out of network office visits. 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. Your 
contract with the Plan says that there is $1000 deductible which applies to Physician/Practitioner services, 
including doctors office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $1000 deductible which applies to Physician/Practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time 
out of network office visits was received on March 24, 2022, to March 31, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for out of network office visits provided from March 24, 2022, to 
March 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on March 
02, 2022, to March 31, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. 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 $35 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $35 copayment for physical therapy visits. This item/service falls within the 
outpatient rehabilitation 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. You have been asked to pay $280 copayment for the physical therapy visits 
which is less than the standard $35 copayment per visit. Therefore, we decided that the Plan does not have to 
waive the copayment for physical therapy visits provided on March 02, 2022, to March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient hospital services and an 
injection provided on May 25, 2022. 
 
You asked the Plan to waive the copayments for outpatient hospital services and an injection. 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 $285 
copayment for Medicare covered outpatient surgery and a $35 copayment for services provided.  
 
 
 You have been asked to pay a total of $148.05 which is less than the standard copayment for outpatient hospital 
services and an injection. This item/service falls within the Outpatient hospital 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 copayments for outpatient hospital services and an injection provided on 
May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation (D9222) and a therapeutic parenteral drug 
(D9610) provided by September 2, 2022. 
 
You asked the Plan to pay for sedation and a parenteral drug. You say that you disagree with the denial for the 
dental services. The Plan denied your request. The Plan says that deep sedation (D9222) and a therapeutic 
parenteral drug (D9610) are not covered by 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 deep 
sedation (D9222) and a therapeutic parenteral drug (D9610) provided by September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care services provided on October 26, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health care services. You say that you were not responsible to obtain the 
authorization and it is the responsibility of the assisted living facility to obtain one. 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 health care services provided on October 26, 
2021, by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement provided on September 22, 2022. 
 
You asked the Plan to pay for debridement. 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 debridement provided 
on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an excision of benign lesion up to 1.25 cm (D7410) provided 
on January 29, 2022. 
 
You asked the Plan to pay for the excision of benign lesion up to 1.25 cm. You say that you are asking for a 
reconsideration and to review the submitted documentation to reprocess this appeal. 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 an 
excision of benign lesion up to 1.25 cm (D7410) provided on January 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on September 18, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99285. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 procedure code 99285. Our reviewer says 
that the medical records do not support the billing of code 99285. Our reviewer found although the history and 
exam criteria are met, the medical decision making (MDM) criteria is not. The enrollee presented with 
symptoms possibly related to a known condition and had already taken medication with resolve of some of the 
symptoms. The only order documented was an electrocardiogram (ECG or EKG). There was no threat to life or 
body function documented. Criteria to report 99285 has not been met. The presenting problem was moderate, 
as was the procedures and management. Procedure code 99284 is a more appropriate code based on the 
documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on September 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for intraoral x-rays (D0220, D0230) provided on 
September 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 your benefit for the requested item or 
service has already been exhausted, the plan will only cover one x-ray per plan year. 
 
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 September 29, 2022. 
Therefore, we decided that the Plan does not have to pay more for intraoral x-rays (D0220, D0230) provided on 
September 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
May 31, 2022, to June 17, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel you should not 
be responsible for this cost share amount, and you would like the Plan to reconsider your request. 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 $160 
copayment per day for days 1-10 for Inpatient hospital care.  
 
You have been asked to pay a $160 copayment per day for days 1-10 for the inpatient hospital stay, totaling 
$1600. 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 the inpatient hospital stay provided from May 31, 2022, to June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vestibuloplasty (D7340). 
 
You asked the Plan to pre-approve the vestibuloplasty. You say that you do not feel it is fair that you have to 
pay out of pocket for this corrective procedure, as it was not your fault. You also say that you do not have the 
funds to cover this procedure. The Plan denied your request. The Plan says this service is not covered under 
your 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 pre-approve a 
vestibuloplasty (D7340).  
 Your complaint about the provider stitching your jaw to your gum where the tooth was pulled from is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided on July 27, 
2022, to September 26, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy. 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 $100 
copayment for radiological diagnostic services. 
 
You have been asked to pay a $100 copayment for radiation therapy. This item/service falls within the 
radiological diagnostic 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. You have been asked to pay $1,800 ($100 x 18 visits) copayment for the 
radiation therapy visits. Therefore, we decided that the Plan does not have to waive the copayment for radiation 
therapy provided on July 27, 2022, to September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on August 08, 2022. 
 
You asked the Plan to pay for rest home 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 rest home visit provided 
on August 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the contact lens fitting provided on September 9, 2022. 
 
You asked the Plan to pre-approve the contact lens fitting. You say that you are appealing the eye exam to refill 
your contact lenses. The Plan denied your request. The Plan says the service is not a covered benefit. 
 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 does not cover this service. 
 
We looked at the file and the Plan's rules. Specifically, the contact lens fitting is not a covered benefit. Based 
on this information, we decided that the Plan's rules for coverage of the contact lens fitting have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the contact lens fitting provided on 
September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the in-home podiatry visit provided on 
August 11, 2022. 
 
You asked the Plan to waive the copayment for the in-home podiatry visit. You say that you cannot afford 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 $35 
copayment per visit for the diagnosis and medical or surgical treatment of injuries and diseases of the feet (such 
as hammer toe or heel spurs), as well as routine foot care and certain medical conditions affecting the lower 
limbs 
 
 
 You have been asked to pay a $35 copayment for the in-home podiatry visit. This item/service falls within the 
podiatry services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the in-home podiatry 
visit provided on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network outpatient surgery 
provided on August 11, 2022. 
 
You asked the Plan to waive the coinsurance for out-of-network outpatient surgery. You say that you disagree 
with the coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 35% 
coinsurance for out-of-network outpatient surgery.  
 
You have been asked to pay a 35% coinsurance for out-of-network outpatient surgery. The total allowed 
amount for the outpatient surgery $500.94. The amount you are being asked to pay is $175.33 ($500.94 x 35% 
=$175.3). 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 out-of-network outpatient surgery provided on 
August 11, 2022.