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

 
We decided that the Plan does not have to waive the copayment for the overnight pulse oximetry test 
performed on April 27, 2022. 
 
You asked the Plan to waive the copayment for the overnight pulse oximetry test. You say that this should have 
been paid for by the Plan. 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 $25 
copayment for Medicare-covered non-radiological diagnostic services, which includes home or lab-based sleep 
studies.  
 
 
 
 
 You have been asked to pay a $22.86 copayment for the overnight pulse oximetry test because the allowed 
amount for this service is less than $25. 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 copayment for 
the overnight pulse oximetry test performed on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D5214) provided on August 3, 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 February 15, 2022. 
Therefore, we decided that the Plan does not have to pay for a cleaning (D5214) provided on August 3, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92004) provided on August 26, 
2022. 
 
You asked the Plan to pay for a medical eye examination (92004). You say that the member had other claims 
that were paid for this date of service with the same diagnosis.. 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 medical eye 
examination (92004) provided on August 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 provided March 9, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says Medicare does not pay any provider or supplier 
other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 provided March 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 2, 2022, to 
March 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 2, 2022, to March 
12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodic oral evaluation (D0120) and periodontal 
maintenance (D4910) provided on September 12, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are on a fixed income, and you do not 
agree with the amount billed. 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. This benefit includes the 
requested periodic oral evaluation (D0120) but is limited to two oral exams twice a year. 
 
  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. You 
had D0120 on January 12, 2022, and April 11, 2022. The record shows your benefit for the requested D0120 
was exhausted on date of service April 11, 2022. Therefore, we decided that the Plan does not have to pay more 
for periodic oral evaluation (D0120) and periodontal maintenance (D4910) provided on September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) and a determination of 
refractive state (92015). We also decided that the Plan does not have to pay more for frames (V2020), single 
lenses (V2103) and impact resistant lenses (V2784) provided on July 23, 2022. 
 
You asked the Plan to pay for a medical eye examination (92014) and a determination of refractive state 
(92015). You also asked the Plan to pay more for frames (V2020), single lenses (V2103) and impact resistant 
lenses (V2784). You say that you were not aware that you have to get authorization or a referral. You also say 
you asked the provider if they accepted your Plan, and they said yes. The Plan denied your request. The Plan 
says you did not get a prior authorization for a medical eye examination (92014) and a determination of 
refractive state (92015). The Plan also says that the benefit is exhausted for frames (V2020), single lenses 
(V2103) and impact resistant lenses (V2784) 
 
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 a medical eye examination (92014) and a determination of refractive state (92015) 
without prior authorization when you get those services from a network provider. The Plan also covers up to 
$200 for lenses (V2103, V2784) and frames (V2020). 
 
We looked at the file and the Plan's rules. The Plan rules say that you can get routine eye examinations (92014, 
92015) without getting prior approval in advance from your PCP, as long as you get them from a network 
provider. The Plan rules also say there is a $200 allowance for eyeglasses, lenses (V2103, V2784) and frames 
(V2020). The Plan rules also say that if the eyewear you purchase costs more than the allowance listed for your 
plan, you pay the difference. The record shows this benefit was exhausted on July 23, 2022. Based on this 
information, we decided that the Plan's rules for coverage of a medical eye examination (92014) a 
determination of refractive state (92015), frames (V2020), single lenses (V2103) and impact resistant lenses 
(V2784) have not been met. Therefore, we decided that the Plan does not have to pay for a medical eye 
examination (92014) and a determination of refractive state (92015). We also decided that the Plan does not 
have to pay more for frames (V2020), single lenses (V2103) and impact resistant lenses (V2784) provided on 
July 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lower partial denture (D5214) provided on March 14, 2022. 
 
You asked the Plan to pay for the dental service. You say that you cannot afford the dental service and would 
like the Plan to cover it. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the lower partial denture is 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 a lower 
partial denture (D5214) provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on August 18, 2022. 
 
You asked the Plan to pay for acupuncture. 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 acupuncture provided on 
August 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on August 31, 2022. 
 
You asked the Plan to waive the copayment for CT scan. 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 $175 
copayment for Outpatient hospital services. 
 
You have been asked to pay a $175 copayment for CT scan. 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 CT scan provided on 
August 31, 2022.
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  The Plan denied your request. The Plan 
says that the admission to a LTACH is not medically necessary. 
 
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 that there is no evidence that you require services that are not currently available at 
the current acute care hospital. You can remain at the current acute care hospital until such time no acute 
services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on 
September 1, 2022, to September 4, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. 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 $290 
copayment per day for days 1 to 7 for inpatient hospital care. This inpatient hospital stay lasted 3 days, 
resulting in a copayment amount of $870 ($290 per day for 3 days = $870). 
 
You have been asked to pay $290 copayment per day for days 1 to 7 for inpatient hospital services. This 
item/service falls within the inpatient hospital 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 inpatient hospital services provided on September 1, 2022, to September 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a medical supply provided on February 
12, 2022. 
 
You asked the Plan to waive the coinsurance for a medical supply. You say that you already paid a copayment 
and feel you should not have to pay anything extra. No one told you that you would have these fees. 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 outpatient diagnostic tests and therapeutic services and supplies. The allowed amount of this 
drug or item is $30.20, resulting in a coinsurance amount of $6.04 ($30.20 x 20% = $6.04). 
 
You have been asked to pay a $6.04 coinsurance for a medical supply. 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 coinsurance for a medical supply provided on February 12, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided on August 8, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendered dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation (D4921) provided on August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 07, 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 July 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral radiographic 
images (D0220 and D0230) provided on September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that exams are covered by your dental plan. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because the limited 
oral evaluation and intraoral radiographic images 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 a limited 
oral evaluation (D0140) and intraoral radiographic images (D0220 and D0230) provided on September 27, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine eye examination (S0620) a determination of 
refractive state (92015) and fundus photography provided on August 23, 2022. 
 You asked the Plan to pay for routine eye examination (S0620) a determination of refractive state (92015). You 
say that this was a diabetic examination and should be covered. The Plan denied your request. The Plan says 
you are indicating that the eye examination and refraction was related to a diabetic exam, however the claim 
was billed as routine care. The Plan also says that fundus photography (92250) is not a covered service under 
your benefits. 
 
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 up to $40 for an out-of-network routine eye examination. The Plan also excludes 
fundus photography from this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover routine eye examinations (S0620, 
92015). Fundus photography (92250) is excluded from this benefit. The Plan rules also say that you pay any 
amount over the $40 allowance for an out-of-network routine eye examination (S0620, 92015). The record 
shows these services were received out-of-network. The record also shows that you received a routine eye 
examination. Based on this information, we decided that the Plan's rules for coverage of routine eye 
examination (S0620) a determination of refractive state (92015) have not been met. Therefore, we decided that 
the Plan does not have to pay for routine eye examination (S0620) a determination of refractive state (92015) 
and fundus photography provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on September 
7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for principal care management services. You say that you had no prior knowledge of 
who you will be required to see. The Plan denied your request. The Plan says an authorization was not obtained 
prior to services being 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 principal care management services provided on 
September 7, 2022, by an out-of-network (OON) provider.