Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on February 8, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you are disputing the coinsurance 
applied because you received the same service on April 04, 2022 and did not have a member responsibility. 
The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for chemotherapy and all other part B drugs at primary care provider or specialist office, in home 
or outpatient setting.  
 
You have been asked to pay $559.11, which is 20% of the allowed amount for the injection  
($2,795.55 x 20% = $559.11). An injection 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 injection provided on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (MILD) 
(0275T). 
 
You asked the Plan to pre-approve the MILD procedure. You say that the requested MILD procedure is 
medically necessary. The Plan denied your request. The Plan says the enrollee is not participating in an 
approved clinical study for evidence development. 
 
The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar 
Decompression (PILD) will be covered by Medicare when provided in a clinical study under section 
1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the minimally invasive lumbar decompression have not been met. Specifically, you are not 
enrolled in a clinical study. Therefore, we decided that the Plan does not have to pre-approve minimally 
invasive lumbar decompression (MILD) (0275T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided by a network provider on April 
12, 2022. 
 
You asked the Plan to pay for the crown (D2740). You say that the Plan previously covered crowns. You say 
your policy is supposed to cover filings, crowns, cleanings, and check-ups. The Plan denied your request. The 
Plan says the service 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 crown (D2740) is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2740) 
provided by a network provider on April 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) on 
May 06, 2021. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing you are being 
charged 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 a 20% 
coinsurance for durable medical equipment (DME). The provider billed in the amount of $359.40 and applied a 
discount of $21 and the Plan paid $270.72. $359.40 -$21 = $338.4 - $270.72 = $67.68. The provider also billed 
in the amount of $7.50 and the Plan paid $6.00. $7.50 - $6.00 = $1.50. $67.68 + $1.50 = $69.18. Therefore, 
results in the total cost sharing amount of $69.18. 
 
 
 
 You have been asked to pay a 20% coinsurance for durable medical equipment (DME). Durable medical 
equipment (DME) 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 coinsurance for durable medical equipment (DME) on May 06, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on February 28, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you feel the visit was unnecessary 
and that you should not be responsible for the $45 copayment. 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 a $45 
copayment for physician specialist services.  
 
You have been asked to pay a $45 copayment for an office visit. An office visit falls 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 an office visit provided on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 25, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the routine venipuncture provided on 
May 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and the routine venipuncture. You say that the services were 
medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
office visit and the routine venipuncture. We found no exception that would require the Plan to pay for the 
office visit and the routine venipuncture. The record shows CPT code 36415 was billed which means the 
provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the 
Plan does not have to pay for the office visit and the routine venipuncture provided on May 3, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient services on May 05, 2022, to 
May 19, 2022. 
 
You asked the Plan to waive the copayments for outpatient services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $285 
copayment for outpatient hospital surgery. We cover medically necessary services you get in the outpatient 
department of a hospital for diagnosis or treatment of an illness or injury. Covered services include but are not 
limited to services in an emergency department or outpatient clinic, such as observation services or outpatient 
surgery. There were two dates of service. $285 x 2 = $570. Therefore, results in the total cost sharing amount 
of $570. 
 
 
  
You have been asked to pay a $285 copayment for each outpatient services. Outpatient services fall 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 copayments for outpatient 
services on May 05, 2022, to May 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for a urinary catheter provided on 
April 18, 2022. 
 
You asked the Plan to waive or reduce the copayment for the catheter. You say that you are being charged 
more that you were previously. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 each durable medical equipment (DME) item.  
 
You have been asked to pay $532.80, which is 20% of the allowed amount for the catheter ($2,664.00 allowed 
amount x 20% coinsurance = $532.80). The catheter 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 or reduce the copayment for a urinary 
catheter provided on April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (A6197, A4450, A6446) 
provided on March 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for durable medical equipment (A6197, A4450, A6446). You say that services were 
rendered in good faith and medically necessary. The Plan denied your request. The Plan says the provider is 
out-of-network and authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for durable medical equipment (A6197, A4450, 
A6446) provided on March 18, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to be in the facility to recover from a 
hospital stay for pneumonia. The Plan denied your request. The Plan says according to the available records, 
you do not meet all the required Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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.  
 
 Our physician reviewer found you do not require the intensity of services provided at an IRF. You have not 
shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. 
Your care needs can be met at a lower level of care such as skilled nursing facility or subacute rehabilitation. 
 
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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mammography on March 18, 2022. 
 
You asked the Plan to waive the copayment for mammography. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $20 
copayment for basic imaging service (e.g., general x-rays or ultrasound). Covered services include but are not 
limited to other outpatient diagnostic tests. 
 
You have been asked to pay a $20 copayment for mammography. Mammography falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for mammography on March 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are requesting SNF services for the enrollee. 
The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that the enrollee require services on an inpatient basis, only in a skilled 
nursing facility. 
 
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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual roots on tooth #29 (D7250) provided 
on May 31, 2022. 
 
You asked the Plan to pay for root removal. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says the removal of residual roots (D7250) is not covered by 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 the 
removal of residual roots on tooth #29 (D7250) provided on May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits with a urologist (99203, 99213) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits with a urologist. You say that you have exhausted your in-
network benefit and was approved for a provider who was 45 minutes away and no longer available. You also 
say you will not go back to any urologist that are in-network. The Plan denied your request. The Plan says 
OON referrals are approved if there is an urgent need or if the care cannot be provided within their main 
network. The service being requested is available within 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 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 
office visits with a urologist (99203, 99213) to be provided by an out-of-network (OON) provider.   
Your complaint about your previous urologist is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating that you 
have a referral. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the denial of the 
LTACH admission was appropriate given the clinical scenario and the guidance presented above. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on April 15, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you should not have a copayment for 
this x-ray, because it was a follow up from a procedure. The Plan denied your request. The Plan says the 
copayment applied was 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 a $40 
copayment for outpatient diagnostic tests from a freestanding radiological facility. 
 
You have been asked to pay a $40 copayment for an x-ray. An x-ray falls within the Outpatient Diagnostic 
Tests from a Freestanding Radiological 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 waive the 
copayment for an x-ray provided on April 15, 2022.