Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid provided on February 8, 2022. 
 
You asked the Plan to pay for a hearing aid. You say that the provider you went to cost $1,800 for two hearing 
aids, versus the $2,000 for each one at one of the stores the Plan wanted you to go to. The Plan denied your 
request. The Plan says you must see a Plan hearing provider to use this benefit. The Plan also says the provider 
you saw is not a Plan hearing provider. 
 
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 you see a Plan hearing provider.  
 
We looked at the file, and the Plan's rules. The Plan rules say you must see a Plan hearing provider in order to 
use this benefit. The record shows that the provider who rendered these services was not a hearing provider 
with the Plan. Based on this information, we decided that the Plan's rules for coverage of a hearing aid have not 
been met. Therefore, we decided that the Plan does not have to pay for a hearing aid provided on February 8, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit provided on February 14, 2022. 
 
You asked the Plan to waive the deductible for office visit. You say that you had an annual wellness. 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 $69.58 deductible which applies to out-of-pocket cost for covered 
service. The annual deductible for covered medical services is $800 for in-network and out-of-network.  
 
The item or service you asked the Plan to waive the deductible for falls within the out-of-pocket cost for 
covered service benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is $69.58 deductible which applies to out-of-pocket cost for covered service. This cost sharing is a 
contractual obligation that had not been met at the time office visit was received on February 14, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for office visit provided on February 
14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (procedure codes L0180, L1686, L2624) provided 
to the enrollee on June 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is evidence of misrepresented services. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided records do not document a practitioner encounter (with history and examination) 
documenting the diagnosis of hip arthritis or a recommendation and medical rationale for the orthotics in 
question in this case.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for orthotics (procedure codes L0180, L1686, L2624) provided to the enrollee on June 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on May 21, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you want to dispute the 
copayment charge for your second visit to the emergency room. 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 $90 
copayment for emergency room visit.  
 
You have been asked to pay $90 copayment for emergency care. This item/service falls within the emergency 
room visit 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 emergency care provided 
on May 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from May 3, 2022, to June 1, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 pay for 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 based on the medical records provided, there is no documentation that the patient 
required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse were not required to safely and effectively provide medically necessary and reasonable treatment from 
May 3, 2022 through June 1, 2022. Records did not document the need for intravenous medications, new tube 
feeding or ostomy care or daily complex wound care or respiratory care. Daily skilled services were not 
required. The patient was walking household distances with stand-by assistance with a rolling walker and was 
stand-by assist for transfers and was set-up assist to contact guard assist for activities of daily living. The 
provided records did not document a significant decline in the patients functional status compared to her prior 
baseline to necessitate daily inpatient skilled therapy services. Services in the nursing facility appear custodial 
in this case from May 3, 2022 through June 1, 2022 with part-time therapy services provided. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from May 3, 2022, to June 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) provided on March 
30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for magnetic resonance angiography (MRA). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 magnetic resonance angiography (MRA) provided 
on March 30, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound on June 30, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you would like to appeal the cost 
share. 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 an ultrasound.  
 
You have been asked to pay a $40 copayment for an ultrasound. This item/service falls within the 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 an ultrasound on June 30, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that this provider was approved with this organization 
effective April 1, 2022. You also say that an email confirmation was received on April 7, 2022, from the Plan. 
The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan 
also says that these services were not approved in advance. 
 
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 psychotherapy provided on June 1, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on February 2, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 x-ray provided on February 2, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on April 
29, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the enrollee has never 
paid for this service before. 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 $45 copayment for each Medicare-covered specialist visit. The total amount allowed was $22.03 
which is less than the copayment amount of $45; therefore, $22.03 was charged as the copayment amount. 
 
  The enrollee has been asked to pay a $22.03 copayment for the specialist office visit. This item/service falls 
within the Medicare-covered specialist visit 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 a specialist office visit provided on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the digital hearing aids (V5261) purchased 
on February 17, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
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 purchased from the Plans select hearing aid vendor.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids in this case were not purchased from 
the Plans select hearing aid vendor. The Plans contract states that hearing aids ordered through providers 
other than the Plans select hearing aid vendor are not covered. Therefore, we decided that the Plan does not 
have to issue reimbursement for the digital hearing aids (V5261) purchased on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 29, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that the enrollee has a dual SNP contract, and 
the services should be paid. The Plan denied your request. The Plan says a referral/authorization was not 
obtained prior to services being 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 chiropractic services provided on July 29, 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 office visit provided on May 23, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says our plan covers all medical services that are medically necessary, these services are 
listed in the plans Medical Benefits Chart (this chart is in Chapter 4 of this booklet) and are obtained 
consistent with plan rules. Enrollees are responsible for paying the full cost of services that arent covered by 
our plan, either because they are not plan covered services, or they were obtained out -of-network and were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for office visit provided on May 23, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the out-of-network mammogram provided 
on June 08, 2022. 
 
You asked the Plan to waive the coinsurance for the out-of-network mammogram. You say that screening 
mammograms should be covered 100% whether the provider is in or out of network. 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 30% 
coinsurance for out-of-network breast cancer screening (mammograms). 
 
You have been asked to pay 30% coinsurance for the out-of-network mammogram. This item/service falls 
within the out-of-network breast cancer screening (mammograms) 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 the out-of-network mammogram provided on June 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acupuncture treatment provided on April 22, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the acupuncture. You say that you spoke to the Plan customer service 
representative. You say that you were entitled to have twelve acupuncture sessions in a three month period 
related to you low back pain. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an acupuncture treatment provided on April 22, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on April 26, 2022, to 
April 27, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you would like to appeal the 
cost share. 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 for outpatient surgery.  
 
You have been asked to pay a $160 copayment for outpatient surgery. 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 outpatient surgery on April 26, 
2022, to April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided June 16, 2022, to June 19, 
2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that the required services could have been provided at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found based on the instability and the severity of the infection and potential for complication, it was 
expected that the enrollee would require hospital services that would likely cross two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided June 16, 2022, to June 19, 2022.  
 
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.