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

 
We decided that the Plan does not have to waive the copayments for a SNF stay provided from January 11, 
2022, to February 13, 2022. 
 
You asked the Plan to waive the copayments for a SNF stay. You say that you are on a fixed income and are 
unable to afford the copayments. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 per 
day for days 1-20, $80 per day for days 21-44, and $0 per day for days 45-100 of a benefit period for a skilled 
nursing facility stay.  
 
 
  You have been asked to pay a total copayment of $1520 for a SNF stay. This total includes a $400 copayment 
for days 1-20 ($20 per day x 20 days = $400) and a $1,120 copayment for days 21-35 ($80 per day x 14 days = 
$1,120).  This item/service falls within Skilled Nursing Facility 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 copayments for a SNF stay provided from January 11, 2022, to February 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on September 1, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with 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 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total amount you are being asked to pay $225. 
This item/service falls within the durable medical equipment (DME) 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 durable medical equipment (DME) provided on September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT). 
 
You asked the Plan to pre-approve TTFT. You say that the records provided support that TTFT is medically 
necessary. The Plan denied your request. The Plan says the medical records do not demonstrate that the 
enrollee adhered to the required hours of therapy for coverage of continued TTFT. 
 
The Plan follows Medicare rules. Medicare rules say that the continued coverage of TTFT is only reasonable 
and necessary when there is objective evidence of adherence to therapy, reviewed by the treating practitioner.  
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 TTFT. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of 
glioblastoma. On June 2, 2022, it is documented, She had to keep it off for about 7 days to work on it. On 
September 8, 2022, it is documented, Compliance was 50-60% over the past 2 months. Average daily use 
from September 28 through October 27, 2022, was 71%. 22 of the 60 days and nights were below 80% usage. 
There is insufficient objective evidence of adherence to therapy, defined as the use of TTFT for an average of 
18 hours per day (excluding days the treating practitioner has documented a medical need to limit or interrupt 
treatment), reviewed by the treating practitioner. Adherence to therapy is defined as the use of TTFT for an 
average of 18 hours per day. Because the documentation does not support that the coverage criteria are met, 
continued coverage of TTFT is denied as not reasonable and 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 TTFT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve tumor treatment field therapy (TTFT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an orthopedic procedure provided from 
June 27, 2022, to July 28, 2022. 
 
You asked the Plan to waive the coinsurance for an orthopedic procedure. You say that you were not notified 
ahead of time about this large coinsurance, and if you had known, you would not have had this done. 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug or item is $1824.06 for 3 
treatments, resulting in a coinsurance amount of $364.80 ($1824.06 x 20% = $364.80). Again, this total is for 
multiple visits. 
 
You have been asked to pay a total $364.80 coinsurance for an orthopedic procedure. This item/service falls 
within the Medicare Part B prescription drugs 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 an orthopedic procedure provided from June 
27, 2022, to July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided from June 18, 2022, 
to June 23, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 physician order for the supplies provided in this case. 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 the durable medical equipment provided from June 18, 2022, to 
June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab test provided on August 12, 2022. 
 
You asked the Plan to waive the copayment for lab test. You say that you are disputing the share cost. 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 $5 
copayment for Outpatient hospital services. 
 
You have been asked to pay a $5 copayment for lab test. 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 copayment for lab test provided on August 
12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy services provided from 
May 4, 2022, to June 22, 2022. 
 
You asked the Plan to waive the copayments for the physical therapy services. You say that these bills have 
gotten out of control, and you still have more appointments. 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 $20 
copayment for each Medicare-covered physical therapy visit.  
 
You have been asked to pay a $180 copayment for physical therapy services ($20 x 9 visits). These 
items/services fall 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. Therefore, we decided that the Plan does not have 
to waive the copayments for physical therapy services provided from May 4, 2022, to June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alveoloplasty in conjunction with extractions (D7310) 
provided on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider coverage 
for the denied dental services. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because alveoloplasty in conjunction with extractions are not covered by the 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 pay for 
alveoloplasty in conjunction with extractions (D7310) provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care services provided on January 3, 2022 to 
January 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for observation care services. You say that it was not your choice who the provider 
was that rendered the services. The Plan denied your request. The Plan says there is no prior 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 observation care services provided on January 3, 
2022 to January 4, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on July 7, 
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 a 
mandibular partial denture (D5214) provided on July 7, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection of laboratory specimen provided on October 11, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for collection of laboratory specimen. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says there is no prior authorization on file for the 
services 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 collection of laboratory specimen provided on 
October 11, 2021, 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 August 08, 2022, to August 10, 
2022. 
 
You asked the Plan to pay for office 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 office visit provided on 
August 08, 2022, to August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adult prophylaxis (D1110) provided on September 22, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you have to get cleaning every four months to 
keep from getting periodontal gum disease. You also say the tarter builds up on your gums. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  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 May 18, 2022. Therefore, 
we decided that the Plan does not have to pay for an adult prophylaxis (D1110) provided on September 22, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional intra-oral x-rays (D0220, D0330, D0230) and 
periodontal scaling and root planing (D4341) provided on September 9, 2022 to September 16, 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 your benefit for the requested item or service has 
already been exhausted. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 9, 2022. 
 
You have also been asked to pay a 30%$ coinsurance for periodontal scaling and root planing (D4341) 
provided on September 16, 2022. This item/service falls within the dental 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 pay for additional intra-oral x-rays (D0220, D0330, D0230) and periodontal scaling and root 
planing (D4341) provided on September 9, 2022 to September 16, 2022
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that that the enrollee has broken ribs and under pain 
management. The therapy will help the enrollee gain strength before discharge. The Plan denied your request. 
The Plan says the SNF care is not medically necessary, and the enrollee's needs can be met at a lower level of 
care such as home with home health rehabilitation services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic drug level monitoring services provided on July 
25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic drug level monitoring. You say that the records attached support the 
services provided. 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 therapeutic drug level monitoring services 
provided on July 25, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility care provided on 
July 5, 2022, to July 21, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility care. You say that you are disputing the 
share cost. 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 $135 
copayment per day for days 21-45 for skilled nursing facility care. This skilled nursing facility care stay lasted 
8 days, resulting in a total copayment amount of $1,080 ($135 per day for 8 days = $1,080). 
 
You have been asked to pay $135 copayment per day for days 21-45 for skilled nursing facility care. This 
item/service falls within the skilled nursing facility 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 skilled nursing facility care provided on July 5, 2022, to July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth (D7240) provided on July 11, 
2022. 
 
You asked the Plan to pay for removal of impacted tooth (D7240). You say that you had to have three lower 
teeth removed due to medication that ruined your teeth. You also say you were lead to believe this would be 
covered. The Plan denied your request. The Plan says a removal of impacted tooth (D7240) is not a listed code 
in your 2022 EOC. 
 
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 the 
removal of impacted tooth (D7240) provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid, digital, binaural (V5261) provided on March 
19, 2022. 
 
You asked the Plan to pay for a hearing aid, digital, binaural (V5261). You say that you did not include 
authorization from your provider with the original documentation. The Plan denied your request. The Plan says 
you are required to use in-network providers for coverage. The Plan also says both providers are out-of-
network. 
 
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 in-network providers are used.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules say that you must use in-network providers for 
hearing services. The record shows this provider was out-of-network. Based on this information, we decided 
that the Plan's rules for coverage of a hearing aid, digital, binaural (V5261) have not been met. Therefore, we 
decided that the Plan does not have to pay for a hearing aid, digital, binaural (V5261) provided on March 19, 
2022.