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

 
We decided that the Plan does not have to pay for the occupational therapy services provided on June 3, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the occupational therapy services. You say that you have provided the 
documentation for the services that were rendered to the enrollee. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 the occupational therapy services provided on 
June 3, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on February 21, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you 
would like the provider to pay for this bill, not the Plan. The Plan denied your request. The Plan says the dental 
services were received from an OON provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an OON 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 OON provider. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on February 21, 
2022 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for joint/bone surgery provided on February 9, 
2022. 
 
You asked the Plan to waive the copayment for joint/bone surgery. You say that you didn't know ahead of time 
about the copayment so you shouldn't have to pay it. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
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 $245 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 
 
 You have been asked to pay $245 copayment for joint/bone surgery. Joint/bone surgery falls within the 
Outpatient Surgery and Other Medical 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 joint/bone surgery 
provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing home consultation services provided on January 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing home consultation services. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not approved in advanced. 
 
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 nursing home consultation services at issue in this appeal. The Plan did 
not pre-approve the nursing home consultation services 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 nursing home 
consultation services provided on January 25, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 10, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. In this case, the claim was billed with the laboratory POS code. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on March 
24, 2022, and April 5, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that this should be covered 
since you fell leaving the hospital and they told you that you weren't the first person to do this. The Plan denied 
your request. The Plan says the copayments applied are correct. 
 
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 $35 
copayment for each Medicare-covered specialist visit.  
 
You have been asked to pay $70 ($35 x 2 visits) copayment for specialist office visits. Specialist office visits 
fall within the Physician/Practitioner Services, Including Doctors 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 specialist office visits provided on March 24, 2022, and April 5, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $175.39 copayment for a biopsy performed on February 9, 
2022. 
 
You asked the Plan to waive the $175.39 copayment for a biopsy. You say that you should not be responsible 
for this copayment because you were not assessed a copayment for the same the procedure performed during 
previous visits. The Plan denied your request. The Plan says the copayment was applied 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 $295 
copayment for Outpatient Surgery and Other Medical Services Provided At Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $175.39 copayment for a biopsy. A biopsy falls within the Outpatient Surgery 
and Other Medical Services Provided At Hospital Outpatient Facilities and Ambulatory Surgical Centers 
benefit category. Your contract with the Plan clearly says that you must pay a $295 copayment for Outpatient 
Surgery and Other Medical Services Provided At Hospital Outpatient Facilities and Ambulatory Surgical 
Centers. However, you have only been asked to pay $175.39, which is less than the $295 copayment amount. 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 $175.39 copayment for a biopsy performed on February 9, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the PT services. You say that you need these services. The Plan denied your 
request. The Plan says out of network services are not covered. The Plan also says there is an in network 
provider available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there is a 
network provider available who can provide the physical therapy services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services to be provided by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker and seat attachment provided on March 22, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the walker and seat attachment. You say that the enrollee switched to the Plan, 
and you would like the last 6 months to be covered. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there are in-network providers who can provide the same service. Also, the 
service rendered was not urgent or emergent. 
 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 a walker and seat attachment provided on March 
22, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tecentriq. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a low-grade 
neuroendocrine tumor, likely carcinoid, and not small cell, which is higher grade. Use of Tecentriq is not 
approved by the Food and Drug Administration (FDA), major drug compendia, or the medical literature. The 
services are therefore not considered safe and effective and reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Tecentriq.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power wheelchair provided on June 22, 2021. 
 
You asked the Plan to pay for the power wheelchair. You say that the enrollee was not in a SNF on the date of 
delivery. The Plan denied your request. The Plan says the rules for reimbursement have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
The claim information shows that the enrollee was in a SNF at the time the wheelchair was provided. Based on 
this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pay for the power wheelchair provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on April 18, 2022, by an out-
of-network provider. 
 
You asked the Plan to pay for chiropractic services. You say that the provider was accepted by all your other 
insurance carriers. The Plan denied your request. The Plan says there is no documentation that you were 
referred to this non-contracted provider by a contracted provider, as well as no indication of any attempt made 
to obtain prior authorization for services. 
 
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 April 18, 2022, 
by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient dermatology visit provided on February 18, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient dermatology visit. You say that you would like to request 
reconsideration for payment. 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 an outpatient dermatology visit provided on 
February 18, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) 
provided on June 22, 2020. 
 
You asked the Plan to waive the copayment for the oxygen equipment. You say that the services should be 
covered as you disagree with the charges, were not made aware of them, and they accumulated over time. The 
Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 20% 
coinsurance for Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the oxygen equipment (allowed is $136.32 x 20% = 
$27.26). Oxygen equipment falls within the Durable Medical Equipment (DME) 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. Therefore, we 
decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) provided 
on June 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic physical therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve aquatic physical therapy. You say that you would like the plan to approve 
these services. The Plan denied your request. The Plan says there are in-network providers available to provide 
these services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
aquatic physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered meals. 
 
You asked the Plan to pre-approve home delivered meals. You say that you have been suffering from angina 
for years. You say that you have never had pain to this level. You also say that the attending physician advised 
your heart attack was caused by congestive heart failure. The Plan denied your request. The Plan says the 
criteria have not been met. 
 
Medicare generally does not cover home delivered meals. However, the Plan offers a meal benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a home delivered meal benefit in excess of Medicare coverage, it only applies following 
discharge from a hospital as an inpatient due to congestive heart failure. The record does not show that you had 
a diagnosis of congestive heart failure at the time of discharge from the hospital. Therefore, we decided that the 
Plan does not have to pre-approve home delivered meals.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from acute rehabilitation. 
The Plan denied your request. The Plan says that there is no clear need for physician visits 3 times per week to 
monitor medical conditions. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
enrollee is medically stable and does not need physical medicine and rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no acute rehab nursing needs identified or documented. At the current functional 
level and low endurance, the enrollee does not need intensive therapies consisting of at least 3 hours of therapy 
per day at least 5 days per week with multidisciplinary approach in an IRF. While the enrollee may benefit 
from continued physical and occupational therapy, the enrollee's rehab needs can be safely provided in a lower 
intensity and alternate setting. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.