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

 
We decided that the Plan does not have to pay for laboratory testing provided on February 04, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that we depend upon the facility staff to verify 
eligibility and to obtain authorization from the patients insurance. The Plan denied your request. The Plan says 
that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on February 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-rays, and extraction 
(D0140, D0220, D0230, D7210) provided on December 21, 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 limited 
oral evaluation, intraoral x-rays, and extraction (D0140, D0220, D0230, D7210) provided on December 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says any out-of-network care that is not considered an emergency or out-of-area 
urgent care will not be covered without a prior authorization. To obtain prior authorization, the enrollee or the 
enrollees doctor may contact Member services for assistance. 
 
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 visit to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0157, G0158, G0300) provided on 
April 16, 2022, to April 28, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 17, 2022. The NOA was not received by the Plan until November 9, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0157, 
G0158, G0300) provided on April 16, 2022, to April 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the ultrasound provided on December 6, 
2022. 
 
You asked the Plan to waive the cost share for the ultrasound. You say that the ultrasound was medically 
necessary, and you should not be charged. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $600 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. Your contract with the Plan also says that there is 20% coinsurance after the 
deductible has been met, for in-network Medicare-covered radiological diagnostic services. 
 
You have been asked to pay $115.54 towards your deductible for the ultrasound. The remaining allowed 
amount after the deductible was satisfied for the ultrasound is $1.96 ($117.60 original allowed amount - 
$115.64 deductible paid = $1.96 remaining allowed amount). The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $600 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
the ultrasound was received on December 6, 2022. 
 
You have also been asked to pay $0.39, which is 20% coinsurance of the remaining allowed amount for the 
ultrasound ($1.96 remaining allowed amount x 20% coinsurance =$0.39.) You have been asked to pay a total 
of $116.03 ($115.54 deductible + $0.39 coinsurance = $116.03). This item/service 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 
cost share for the ultrasound provided on December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 27, 
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 December 09, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
December 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on November 30, 2022. 
 
You asked the Plan to pay for home health services. You say that you are requesting the submitted 
documentation be reviewed. 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 home health services 
provided on November 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network chemotherapy treatment 
provided on January 18, 2022. 
 
You asked the Plan to waive the coinsurance for an in-network chemotherapy treatment. You say that you were 
never sent the Evidence of Coverage, threrefore, you did not know about the co-insurance. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an in-network chemotherapy treatment. 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. The allowed amount of this drug is $490.40, resulting in a 
coinsurance amount of $98.08 ($490.40 x 20% = $98.08). Therefore, we decided that the Plan does not have to 
waive the coinsurance for an in-network chemotherapy treatment provided on January 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the service will provide the care needed 
for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 
acute care and is currently unstable for transfer to an LTACH. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute inpatient onservation provided on September 21, 
2022. 
 
You asked the Plan to pay for an acute inpatient onservation. 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 an acute inpatient 
onservation provided on September 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF services provided from June 6, 2022, 
to June 17, 2022. 
 
You asked the Plan to waive the copayment for SNF services. You say that you shouldn't be responsible to pay 
for your SNF stay due to the unacceptable facility conditions and inadequate care. 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 $0 
copayment for days 1 to 20 and a $188 copayment per day for days 21 to 100 for SNF care for SNF care.  
 
  You have been asked to pay a $1,128 copayment for SNF services ($188 per day x 6 days = $1,128). This 
item/service falls within the SNF 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 
SNF services provided from June 6, 2022, to June 17, 2022.  
 
Your complaint about inadequate care and the condition of the facility 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 a ophthalmology visit provided on December 14, 2022. 
 
You asked the Plan to pay for a ophthalmology visit. You say that this was medically necessary and should be 
covered. We have been seeing this patient for years. 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 ophthalmology visit 
provided on December 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on December 07, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you did not actually have a fracture. 
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 outpatient diagnostic imaging, including x-rays. 
 
You have been asked to pay a $20 copayment for the x-ray. This item/service falls within the outpatient 
diagnostic imaging, including x-rays 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 
the x-ray provided on December 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation and cleaning (D0120, 
D1110) provided on January 12, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for a periodic oral evaluation and cleaning 
(D0120, D1110) provided on January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and eye exam provided on November 28, 
2022. 
 
You asked the Plan to pay for the office visit and eye exam. 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 office visit and eye 
exam provided on November 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for electrocardiogram provided on December 
16, 2022. 
 
You asked the Plan to waive the copayment for electrocardiogram. You say that you were advised that there 
would be no 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 $40 
copayment for outpatient hospital services. 
 
You have been asked to pay a $40 copayment for electrocardiogram. 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 
electrocardiogram provided on December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 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 dental services were received from an out-of-
network 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 out-of-network 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 out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation (D0140) provided on September 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on December 07, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting the submitted 
documentation be reviewed. 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 skilled nursing facility 
care provided on December 07, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
August 4, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not have 
to pay for a service that was done a year and a half ago. 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 $200 
copayment for Medicare-covered ambulance services.   
You have been asked to pay a $66.43 copayment for the ambulance transportation because you have met your 
maximum out-of-pocket amount during this service. This item/service falls within the ambulance 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 the ambulance transportation 
provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vison care provided on December 01, 2022. 
 
You asked the Plan to waive the copayment for vison care. You say that you disagree with 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 $45 
copayment for vison care. 
 
You have been asked to pay a $45 copayment for vison care. This item/service falls within the vison 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 vison care provided on 
December 01, 2022.