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

 
We decided that the Plan does not have to pay for subsequent nursing facility visits provided on August 19, 
2022, to August 22, 2022. 
 
You asked the Plan to pay for subsequent nursing facility visits. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility visits provided on August 19, 2022, to August 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from  
July 27, 2021, to July 26, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that these services should be covered in 
full under your Part D Medicare 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 20% 
coinsurance for in-network Medicare-covered Part B drugs and drug administration.  
 
You have been asked to pay $1,118.12 for Part B drugs administered on July 27, 2021, April 26, 2022, and July 
26, 2022. This item/service falls within the in-network Medicare-covered Part B drugs and drug administration 
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 Medicare Part B drugs provided from July 27, 
2021, to July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network specialist office visit 
provided on December 01, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network specialist office visit. You say that you 
disagree with the copaymet. 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 $65 
copayment for out-of-network physician/practitioner services/specialist. 
 
You have been asked to pay a $65 copayment for an out-of-network specialist office visit. This item/service 
falls within the out-of-network physician/practitioner services/specialist 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 out-of-network specialist office visit provided on December 01, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 25, 
2022. 
 
You asked the Plan to pay for the abdominal ultrasound. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
enrollees terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 25, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home psychiatric evaluation provided on September 07, 
2022. 
 
You asked the Plan to pay for home psychiatric evaluation. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home psychiatric 
evaluation provided on September 07, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic imaging provided on August 10, 2022. 
 
You asked the Plan to pay for diagnostic imaging. You say that you are requesting a reconsideration for the 
denied payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for diagnostic imaging provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance applied to the bitewings - four radiographic 
images (D0274). We also decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150), and topical application of fluoride varnish (D1206) provided on November 7, 2022. 
 
You asked the Plan to waive the coinsurance for the bitewing x-rays. You also asked the Plan to pay for the 
dental services represented by codes D0150 and D0274. You say that you needed the appointment with the 
dentist for clearance for an upcoming surgery. You also say that the x-rays were old and the dentist needed new 
ones completed. The Plan says the coinsurance was appropriately applied to the bitewing x-rays provided. The 
Plan says that the dental services represented by code D0150 has already been exhausted, and D0274 is not 
covered under the Plans dental benefits. 
 
You have been asked to pay a 50% coinsurance for the bitewing x-rays. The bitewing x-rays were received 
from an out-of-network provider. This service falls within the bitewing x-rays provided out-of-network 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 the bitewing x-rays.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental service represented by code 
D0274 is not among those covered under this benefit. The record shows your benefit for the comprehensive 
oral evaluation (D0150) was exhausted on dates of service April 22, 2022 and May 23, 2022. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and topical application 
of fluoride varnish (D1206) provided on November 7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on September 13, 
2022. 
 
You asked the Plan to pay for outpatient mental health services. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient mental health 
services provided on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient hospital clinic visit provided 
by an in-network provider on September 8, 2022. 
 
You asked the Plan to waive the deductible for the outpatient hospital clinic visit. You say that you think that 
the cost sharing should be lower. 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 says that until you have paid your $680 
deductible, you must pay the full cost for most of your covered services, and your deductible applies to all in-
network services besides primary care provider services, specialist services, and lab services. 
 
 
 
 
 
 You have been asked to pay a $126.20 deductible for the outpatient hospital clinic visit. This item or service 
you asked the Plan to waive the deductible for falls within the outpatient hospital services benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $680 deductible which 
applies to outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the 
time the outpatient hospital clinic visit was provided on September 8, 2022. Therefore, we decided that the Plan 
does not have to waive the deductible for the outpatient hospital clinic visit provided by an in-network provider 
on September 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on August 18, 2022. 
 
You asked the Plan to pay for physical therapy. 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 physical therapy 
provided on August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotic footwear provided on September 28, 2022. 
 
You asked the Plan to pay for the orthotic footwear. You say that you need the footwear to use with your brace, 
and you were informed that you would only have a 10% coinsurance. 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 orthotic footwear 
provided on September 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vertebroplasty/kyphoplasty. 
 
You asked the Plan to pre-approve vertebroplasty/kyphoplasty. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered under certain conditions. 
 
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 vertebroplasty/kyphoplasty. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the low back pain 
was noted to impact his daily functioning. However, there are no follow-ups provided after the January 23, 
2023 procedure to corroborate ongoing symptomatology to support the procedure at L5. These findings were 
all documented prior to the procedure at the L1 and L4 compression fracture sites. A follow-up would be 
needed to corroborate ongoing symptoms that would meet the LCD criteria to support the procedure at L5. 
Additionally, the magnetic resonance imaging (MRI) demonstrates mild retropulsion of the posterior superior 
cortex at L5, which is a relative contraindication. Therefore, the enrollee does not meet the coverage criteria 
detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebroplasty/kyphoplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve vertebroplasty/kyphoplasty.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the periodontal scaling and root planing-four or more teeth per quadrant 
(D4341 x 3) provided from September 7, 2022, through October 19, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that you have exhausted the allowable benefit 
for these services. 
 
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 contract states that periodontal scaling and root planing is 
covered once per quadrant every two years. The Plan has stated that on January 9, 2021, you exhausted the 
allowable benefit for the services provided in this case. However, the Plan has not provided substantive 
evidence that demonstrates these services were provided to you on this day or that payment was issued by the 
Plan. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided 
that the Plan has to pay for the periodontal scaling and root planing-four or more teeth per quadrant  
(D4341 x 3) provided from September 7, 2022, through October 19, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 9, 
2022, to June 13, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you do not feel the 
enrollee is responsible for 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $360 copayment per day for days 1-5 for inpatient hospital care.  
 
The enrollee has been asked to pay a $360 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay is $1,080 ($360 x 3 days = $1,080). This item/service falls within the 
inpatient hospital 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 
inpatient hospital care provided on June 9, 2022, to June 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pulmonary rehabilitation services provided 
on August 22, 2022. 
 
You asked the Plan to waive the copayment for pulmonary rehabilitation services. You say that you disagree 
with the copaymet. 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 pulmonary rehabilitation services. 
 
You have been asked to pay a $20 copayment for pulmonary rehabilitation services. This item/service falls 
within the pulmonary rehabilitation 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 pulmonary rehabilitation services provided on August 22, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical procedure provided on September 2, 2022. 
 
You asked the Plan to pay for a surgical procedure. You say that you are requesting a review of the claim and 
proper payment to be submitted. The Plan denied your request. The Plan says Original Medicare is responsible 
for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on September 1, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for a surgical procedure 
provided on September 2, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic imaging provided on September 9, 2022. 
 
You asked the Plan to pay for diagnostic imaging. You say that you are requesting a reconsideration for the 
denied payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for diagnostic imaging provided on September 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under codes 81162, 81201, 81292, 
81298, 81317, and 81321 provided on September 14, 2022. 
 
You asked the Plan to pay for laboratory services billed under codes 81162, 81201, 81292, 81298, 81317, and 
81321. 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 laboratory services 
billed under codes 81162, 81201, 81292, 81298, 81317, and 81321 provided on September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 24, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on March 24, 2022.