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

 
We decided that the Plan does not have to pay for a biopsy procedure provided on August 17, 2022. 
 
You asked the Plan to pay for a biopsy procedure. 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 a biopsy procedure 
provided on August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous injection provided on August 25, 2022. 
 
You asked the Plan to pay for intravenous injection. 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 intravenous injection 
provided on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telemedicine visit provided on 
November 23, 2022. 
 
You asked the Plan to waive the copayment for a specialist telemedicine visit. You say that you were not told 
that there was a cost share for this service. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each specialist telemedicine visit. 
 
You have been asked to pay a $40 copayment for a specialist telemedicine visit. This item/service falls within 
the each specialist telemedicine 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 a 
specialist telemedicine visit provided on November 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 03, 2022, to January 
31, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
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 January 03, 2022, to January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 11, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
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 September 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote patient monitoring services provided on August 13, 
2022. 
 
You asked the Plan to pay for remote patient monitoring services. You say that you are appealing the claim 
payment denial. 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 patient 
monitoring services provided on August 13, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network mental health visits provided on 
May 11, 2022, to May 24, 2022. 
 
You asked the Plan to waive the copayment for in-network mental health visits. You say that these were short 
visits and you would like the copayments removed. 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 $176 
copayment for outpatient mental health care. 
 
You have been asked to pay a $176 copayment for in-network mental health visits. This item/service falls 
within the outpatient mental health 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. You had two visits, each has a $90 copayment. You were charged the 
allowed amount of $86 for one of them, therefore, your total copayment amount is $176 ($86 + $90 = $176). Therefore, we decided that the Plan does not have to waive the copayment for in-network mental health visits 
provided on May 11, 2022, to May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on November 02, 2022. 
 
You asked the Plan to pay for chiropractic 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 chiropractic care 
provided on November 02, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cataract removal with insertion of 
intraocular lens prosthesis (66991) provided on December 13, 2022. 
 
You asked the Plan to waive the copayment for cataract removal with insertion of intraocular lens prosthesis 
(66991). You say that you were not aware you had a $350 outpatient 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 $350 
copayment for per day for other outpatient procedures and services, including, but not limited to outpatient 
surgery performed in an outpatient hospital or ambulatory surgical center. 
 
You have been asked to pay a $350 copayment for cataract removal with insertion of intraocular lens prosthesis 
(66991). This item/service falls within the per day for other outpatient procedures and services, including, but 
not limited to outpatient surgery performed in an outpatient hospital or ambulatory surgical center 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 cataract removal with insertion of intraocular 
lens prosthesis (66991) provided on December 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are unsuccessful in retrieving blood samples as 
your fingers no longer produce sufficient blood to run an accurate reading on the meter. The Plan denied your 
request. The Plan says you do not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on October 28, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that these services were medically neccesary. 
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 October 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020) progressive lens (V2781), photochromatic 
tint (V2744), lenses (V2783), and anti-reflective coating (V2750) provided on October 29, 2022. 
 
You asked the Plan to pay for frames (V2020) progressive lens (V2781), photochromatic tint (V2744), lenses 
(V2783), and anti-reflective coating (V2750). You say that the provider never told you that benefits were for 
every two years as opposed to every year. You also say the services were medically necessary. The Plan denied 
your request. The Plan says they issued payment for the first eyewear purchased on date of service October 23, 
2021. 
 
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 covers one pair of standard lenses and frames every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one pair of standard lenses 
and frames every two years. The Plan rules also say that you receive a $200 allowance towards your purchase 
of frames and standard lenses are covered in full. The record shows this benefit was exhausted on October 23, 
2021. Based on this information, we decided that the Plan's rules for coverage of frames (V2020) progressive 
lens (V2781), photochromatic tint (V2744), lenses (V2783), and anti-reflective coating (V2750) have not been 
met. Therefore, we decided that the Plan does not have to pay for frames (V2020) progressive lens (V2781), 
photochromatic tint (V2744), lenses (V2783), and anti-reflective coating (V2750) provided on October 29, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the lab services provided on November 4, 
2021. 
 
You asked the Plan to waive the cost sharing for the lab services. You say that you would like the cost sharing 
to be lower. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that you have a $700 deductible, which applies to lab services, and after the 
deductible is paid, you must pay a 20% coinsurance of the total cost for each Medicare-covered lab service. 
 
 
 
 
 
 
 You have been asked to pay a cost share of $715.72 for the lab services ($1681.57 allowed amount x .20 = 
$336.31 coinsurance) ($379.41 deductible + $336.31 coinsurance = $715.72). The items or services you asked 
the Plan to waive the cost sharing for falls within the outpatient diagnostic tests and therapeutic services and 
supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $700 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost 
sharing is a contractual obligation that had not been met at the time the lab services were received on 
November 4, 2021. Therefore, we decided that the Plan does not have to waive the cost sharing for the lab 
services provided on November 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sleep medicine testing procedures provided on August 18, 
2022. 
 
You asked the Plan to pay for sleep medicine testing procedures. 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 sleep medicine testing 
procedures provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for a cone beam computed tomography (CT) scan, 
endosteal implant, bone graft, and a cutting procedure (D0367, D7250, D6104, 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 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. Therefore, we decided that the Plan does not have to pay for to pay for 
a cone beam computed tomography (CT) scan, endosteal implant, bone graft, and a cutting procedure (D0367, 
D7250, D6104, D6010) provided on September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (K0553) provided on 
November 20, 2022. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the date of service billed on this claim does not match the 
shipping date or the date or delivery. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery to support the supplies provided in this case. The record 
shows that the shipping date of this item was November 14, 2022, and the delivery date was November 17, 
2022. Therefore, the date of service billed on this claim, November 20, 2022, does not meet Medicare rules. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (K0553) 
provided on November 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for frames (V2020), polycarbonate lenses (V2784) and 
anti-reflective coating (V2750) provided on July 8, 2022. 
 
You asked the Plan to reimburse for frames (V2020), polycarbonate lenses (V2784) and anti-reflective coating 
(V2750). You say that you did use a Plan provider for the eye examination. You also say that the policy never 
stated that you would not be reimbursed if you did not get glasses from the same provider. The Plan denied 
your request. The Plan says the provider that performed these services is not in the Plan vision network. 
 
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 covers these services when you see an in-network vision provider with the Plan. 
 
You are requesting vision services from an out-of-network provider. Though the Plan offers a vision 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 reimburse for frames 
(V2020), polycarbonate lenses (V2784) and anti-reflective coating (V2750) provided on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown 
(D2954) provided on November 14, 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. 
 
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 item provided is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated post 
and core in addition to a crown (D2954) provided on November 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a continuous glucose monitor (CGM) and supplies 
(A4239, E2103). 
 
You asked the Plan to preapprove the CGM and supplies. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as you do not 
meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to preapprove a continuous glucose monitor (CGM) and 
supplies (A4239, E2103).