Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 12, 2022, to 
September 10, 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 August 12, 2022, to 
September 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on October 5, 2022. 
 
You asked the Plan to pay for an eye refraction. You say that this should be covered because the provider had 
you come back for a follow up to check your peripheral vision. The Plan denied your request. The Plan says the 
benefit is exhausted.  
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 one routine eye examination (refraction) per calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules say that routine eye examinations are covered once 
per calendar year. The record shows that this benefit was exhausted on April 14, 2022. Based on this 
information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we 
decided that the Plan does not have to pay for an eye refraction provided on October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a medical eye examination and evaluation with initiation of diagnostic 
treatment program (92002) provided on September 28, 2022. 
 
You asked the Plan to pay for a medical eye examination and evaluation with initiation of diagnostic treatment 
program (92002). You say that you were not told that this provider was not in-network. The Plan denied your 
request. The Plan says that not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not supported their denial reason that the out-of-
network services in dispute are non-covered. The code in dispute is 92002 representing a medical examination 
and evaluation with initiation or continuation of a diagnostic and treatment program with an ophthalmologist. 
The Plan did not provide any medical records to support that the services provided were routine in nature. The 
Plan contract clearly says that the Plan will reimburse a maximum of $3,000 for out-of-network (POS) services 
per calendar year for consultation, diagnosis, and treatment by a specialist. The Plan has not provided any 
evidence that this benefit was exhausted on the date of service in dispute. Therefore, we decided that the Plan 
has to pay for a medical eye examination and evaluation with initiation of diagnostic treatment program 
(92002) according to the out-of-network (POS) benefit provided on September 28, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 30, 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 June 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
September 11, 2022, to September 14, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital 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 $300 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $300 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay is $900 ($300 x 3 days = $900). 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 care 
provided on September 11, 2022, to September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a counseling visit to discuss needs for screening provided on 
September 22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a counseling visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
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 a counseling visit to discuss needs for screening 
provided on September 22, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network outpatient diagnostic tests 
provided on July 18, 2022. 
 
You asked the Plan to waive the copayment for out-of-network outpatient diagnostic tests. 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 $160 
copayment for out-of-network outpatient diagnostic tests.  
 
You have been asked to pay a $160 copayment for out-of-network outpatient diagnostic tests. This item/service 
falls within the out-of-network outpatient diagnostic 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 out-of-network outpatient diagnostic tests provided on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on October 15, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. 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 $10 
copayment for physician/practitioner services/primary care providers.  
 
You have been asked to pay a $10 copayment for an office visit. This item/service falls within the 
physician/practitioner services/primary care providers 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 October 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on August 25, 2022. 
 
You asked the Plan to pay for the drug testing. You say that the services were medically necessary. 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 drug testing 
provided on August 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
September 14, 2022, to September 18, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $295 
copayment per day for days 1 to 6 for inpatient hospital care. This inpatient hospital stay lasted 4 days, 
resulting in a copayment amount of $1,180 ($295 per day for 4 days = $1,180). 
 
You have been asked to pay $295 copayment per day for days 1 to 6 for inpatient hospital care. 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 care provided on September 14, 2022, to September 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on April 02, 2022, to April 26, 
2022. 
 
You asked the Plan to pay for chiropractic care. 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 chiropractic care 
provided on April 02, 2022, to April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit, an electrocardiogram and influenza 
vaccine provided on September 24, 2022. 
 
You asked the Plan to pay for an annual wellness visit, an electrocardiogram and influenza vaccine. You say 
that you are appealing the claim payment denial. 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 annual wellness visit, 
an electrocardiogram and influenza vaccine provided on September 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on July 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the reports attached support the services 
provided. The Plan denied your request. The Plan says the services rendered were not medically necessary. 
 
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 nursing facility care provided on July 12, 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 nursing facility care provided on March 29, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says there is no authorization on file for the services 
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 nursing facility care provided on March 29, 2022, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy provided on August 13, 2022. 
 
You asked the Plan to pay for home infusion therapy. You say that due to covid our office has been 
understaffed and were unable to obtain the proper paperwork. 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 infusion therapy 
provided on August 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. 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 $155 
copayment for outpatient diagnostic tests/Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $155 copayment for outpatient diagnostic tests. However, you are being asked to 
pay $111.10 which is less than the required amount. This item/service falls within the outpatient diagnostic 
tests/Medicare-covered radiological diagnostic 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 outpatient diagnostic tests.  Medicare does not permit us to make decisions on payments already made. Contact the Plan about previously made 
payments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of intra-socket biological dressing (D7922), 
bone replacement graft (D7953), general anesthesia (D9219, D9222, and D9223), and therapeutic drugs 
(D9612) for tooth #19. 
 
You asked the Plan to pre-approve the dental services. You say that the extraction was approved so these dental 
procedures should be approved too. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because the placement of intra-socket biological dressing, bone replacement grafts, 
general anesthesia, and therapeutic drugs 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 pre-approve 
placement of intra-socket biological dressing (D7922), bone replacement graft (D7953), general anesthesia 
(D9219, D9222, and D9223), and therapeutic drugs (D9612) for tooth #19.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on 
September 11, 2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that the appellant should not 
have to pay the copay for such a poor experience. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment for emergency care.  
 
The enrollee has been asked to pay a $90 copayment for emergency room visit. This item/service falls within 
the emergency care benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
emergency room visit provided on September 11, 2022.
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 out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that services with this provider were approved in 
the past. The Plan denied your request. The Plan says network providers are available to provide necessary 
care. 
 
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 out-of-network (OON) provider.