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

 
We decided that the Plan does not have to pay for outpatient surgery provided on August 29, 2022, to 
September 01, 2022. 
 
You asked the Plan to pay for outpatient surgery. 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 outpatient surgery 
provided on August 29, 2022, to September 01, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 29, 2022, 
through August 31, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on August 29, 2022 with complaint of a 
mechanical fall. His left arm was outstretched and it caused injury and deformity. The review has determined 
that the record showed that at the time of the inpatient admission, the admitting physician reasonably expected 
that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from August 29, 2022, through August 31, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildups, including any pins when required  
(D2950 x 2), porcelain/ceramic pontic (D6245), and the porcelain/ceramic retainer crowns (D6740 x 2) 
provided on June 1, 2022. 
 
You asked the Plan to pay 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 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 items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildups, 
including any pins when required (D2950 x 2), porcelain/ceramic pontic (D6245), and the porcelain/ceramic 
retainer crowns (D6740 x 2) provided on June 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an in-network knee x-ray provided on 
October 14, 2022. 
 
You asked the Plan to reduce the coinsurance for an in-network knee x-ray. You say that this should have been 
a lower copayment and not the 20% coisurance. 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% 
coinsurance for basic radiological services. 
 
You have been asked to pay 20% coinsurance for an in-network knee x-ray. This item/service falls within the 
basic radiological 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. The allowed amount of this x-ray is $447, resulting in a coinsurance amount of $89.40 
($447 x 20% = $89.40). Therefore, we decided that the Plan does not have to reduce the coinsurance for an in-
network knee x-ray provided on October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist eye visit provided 
on October 20, 2022. 
 
You asked the Plan to waive the copayment for an in-network specialist eye visit. You say that you went in for 
routine eye care, and want the visit to be coded as such. The provider didnt tell you they were doing tests that 
would change the visit type. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes. 
 
You have been asked to pay a $35 copayment for an in-network specialist eye visit. This item/service falls 
within the Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes 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 in-network specialist eye visit provided on 
October 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
December 02, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not think you 
should have to pay the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each emergency care visit. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
each emergency care 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 an 
emergency room visit provided on December 02, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on September 12, 2022. 
 
You asked the Plan to pay for physical therapy. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have a policy for $1,500 for covered 
services. You also say that you have not used $600 and still have $950 available for plan year 2022. 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 April 12, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - three surfaces, anterior tooth #'s 6, 
24, 25, and 27 (D2332), resin-based composite - four or more surfaces or involving incisal angle tooth #8 
(D2335), intraoral - periapical first radiographic image (D0220), resin-based composite - two surfaces, anterior 
tooth #'s 9 and 10 (D2331) provided on July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that your annual 
maximum was nearly exhausted. The Plan denied your request. The Plan says your benefit for the requested 
items or services $1,000 dollar limit was met. 
 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 items or services was exhausted on date of service July 13, 2022. 
Additional services were received on this date of service for CPT code D2954, prefabricated post and core in 
addition to crown, tooth #20, which paid in the amount of $87. These procedure codes accumulate to your 
annual limit of $1,000 therefore you have maxed the allowable benefit for the year. Therefore, we decided that 
the Plan does not have to pay for resin-based composite - three surfaces, anterior tooth #'s 6, 24, 25 and 27 
(D2332), resin-based composite - four or more surfaces or involving incisal angle tooth #8 (D2335), intraoral - 
periapical first radiographic image (D0220), resin-based composite - two surfaces, anterior tooth #'s 9 and 10 
(D2331) provided on July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 15, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the records provided support medical 
necessity. 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 the laboratory services 
provided on April 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network lab services provided on 
September 08, 2022. 
 
You asked the Plan to waive the copayment for in-network lab services. You say that you feel this lab has been 
coded incorrectly. 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 $10 
copayment for diagnostic lab services and diagnostic procedures and tests. 
 
You have been asked to pay a $10 copayment for in-network lab services. This item/service falls within the 
diagnostic lab services and diagnostic procedures and tests 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 in-network lab services provided on September 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the glucose test strips to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the glucose test strips. The Plan denied your request. The Plan says that this 
item is not covered under your plan as it is not the preferred company brand. 
 
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 items and services 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 
the glucose test strips to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. You say that you need to continue the treatment you are 
already receiving from your current provider. The Plan denied your request. The Plan says you must receive 
your care from a network provider. 
 
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 
an office visit to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network lab services provided on 
October 21, 2022. 
 
You asked the Plan to waive the copayment for in-network lab services. You say that you should not have such 
a big copayment for labs. 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 $50 
copayment for lab services - outpatient hospital. 
 
You have been asked to pay a $50 copayment for in-network lab services. This item/service falls within the lab 
services - outpatient hospital 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 in-network 
lab services provided on October 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-emergent ambulance ride provided on August 18, 
2022. 
 
You asked the Plan to pay for a non-emergent ambulance ride. 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 non-emergent 
ambulance ride provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography (92250) provided on October 12, 
2022. 
 
You asked the Plan to pay for the fundus photography. You say that you have never had to pay for these 
appointments. The Plan denied your request. The Plan says this claim was processed correctly according to 
your plan documents. 
 
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. 
 
We looked at the file and the Plan's rules. The contract clearly states that you are responsible for a $20 copay 
for each Medicare-covered eye exam. The record shows that you received a fundus photography (92250) and 
you have been asked to pay $16.73, which is less than the standard $20 copayment for this service. Based on 
this information, we decided that the Plan's rules for coverage of the fundus photography have not been met. 
Therefore, we decided that the Plan does not have to pay for the fundus photography (92250) provided on 
October 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cystoscopy provided on October 04, 
2022. 
 
You asked the Plan to reduce the copayment for the cystoscopy. You say that you were informed that you 
would only have the office visit 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 outpatient surgery services at a hospital outpatient facility. 
 
You have been asked to pay a $350 copayment for the cystoscopy. This item/service falls within the outpatient 
surgery services at a hospital outpatient facility 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 reduce the 
copayment for the cystoscopy provided on October 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the single vision lenses (V2100) and frames (V2020) 
purchased on September 12, 2022, from an out-of-network provider. 
 
You asked the Plan to pay for the single vision lenses and frames. You say that you believe it does not seem 
right that as a senior citizen on a limited income, you should be penalized for going out-of-network when you 
can find a good, less expensive product. The Plan denied your request. The Plan says you purchased single 
lenses and frames from a non-participating provider, and direct reimbursement is not available through your 
vision benefit for services submitted. The Plan also says an in-network provider must provide these services. 
 
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 they are purchased from an in-network provider. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you purchased this eyewear from 
an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the 
single vision lenses and frames have not been met. Therefore, we decided that the Plan does not have to pay for 
the single vision lenses (V2100) and frames (V2020) purchased on September 12, 2022, from an out-of-
network provider.