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

 
We decided that the Plan does not have to pay for nursing facility care provided on August 19, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that these 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 nursing facility care 
provided on August 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each wound debridement service provided 
on November 29, 2022, to December 06, 2022. 
 
You asked the Plan to reduce the copayment for each wound debridement service. You say that you were told 
you only had to pay $77 and think this copayment amount is unfair. 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 $295 
copayment for in-network outpatient surgery at an outpatient hospital. 
 
You have been asked to pay a $295 copayment for each wound debridement service. This item/service falls 
within the in-network outpatient surgery at an outpatient hospital 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 reduce the copayment for each wound debridement service provided on November 29, 2022, to December 
06, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the nuclear medicine stress test, drug 
injection, and medical supplies provided on June 29, 2022. 
 
You asked the Plan to waive the cost share for the stress test, drug injection, and medical supplies. You say that 
the provider charged too much for these services. 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 in-network outpatient radiological diagnostic services, including nuclear medicine studies. Your 
contract with the Plan also clearly says you must pay 20% coinsurance for in-network Medicare Part B drugs. 
Your contract with the Plan also clearly says you must pay 20% coinsurance for in-network medical supplies. 
 
You have been asked to pay a $175 copayment for the stress test. You have also been asked to pay $123.20, 
which is 20% coinsurance of the allowed amount for the medical supplies ($616 allowed amount x 20% 
coinsurance = $123.20). These items/services fall within the outpatient diagnostic tests and therapeutic services 
benefit category. 
 
You have also been asked to pay $49.03, which is 20% coinsurance of the allowed amount for the drug 
injection ($245.16 allowed amount x 20% coinsurance = $49.03). This item/service falls within the Medicare 
Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the cost share for the nuclear medicine stress 
test, drug injection, and medical supplies provided on June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on July 26, 2022. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
July 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on July 25, 2022. 
 
You asked the Plan to pay for podiatry services. 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 podiatry services 
provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with denial of requested 
services. 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. This benefit includes the 
requested complete denture - maxillary (D5110) but is limited to one per 60 floating months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you had covered D5110 on February 1, 2022; therefore, your benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pre-approve complete denture - maxillary (D5110).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the eyelid repair procedure to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the eyelid repair procedure. You say that you were not told that this 
provider was out-of-network. The Plan denied your request. The Plan says you must receive your care from a 
network provider. 
 
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 
the eyelid repair procedure to be provided by an out-of-network (OON) provider.
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 say that the redirected provider does not 
perform the procedure you need. The Plan denied your request. The Plan says the enrollee must receive their 
care from a network provider (for more information about this, see Section 2 in Chapter 3). In most cases, care 
the enrollee receives from an out-of-network provider (a provider who is not part of the plans network) will 
not be covered. This means that the enrollee will have to pay the provider in full for the services furnished. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occupational therapy evaluation provided on November 
28, 2022. 
 
You asked the Plan to pay for an occupational therapy evaluation. 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 an occupational therapy 
evaluation provided on November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the specialist visit. You say that you would like to continue care with this 
provider. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 
the specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - full cast high noble metal tooth #7 (D2790). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says your 
benefit for the crown - full cast high noble metal 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 crown - full cast high noble metal was exhausted on date of service May 26, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a crown - full cast high noble metal tooth #7 
(D2790).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist office visit provided on 
January 04, 2023, to January 18, 2023. 
 
You asked the Plan to waive the copayment for each specialist office visit. You say that these services were a 
continuation of a previous surgery. 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 $35 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for each specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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 each specialist office visit provided on January 04, 2023, to January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acupuncture services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the acupuncture services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says enrollees must receive their care from a network 
provider. 
 
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 
the acupuncture services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on November 21, 2022. 
 
You asked the Plan to pay for occupational therapy. 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 occupational therapy 
provided on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a polymerase chain reaction (PCR) culture of a wound 
provided on October 25, 2022. 
 
You asked the Plan to pay for a polymerase chain reaction (PCR) culture of a wound. You say that this is 
supported in the records. 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 polymerase chain 
reaction (PCR) culture of a wound provided on October 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the bone marrow aspiration and the 
laboratory services provided on July 8, 2022. 
 
You asked the Plan to waive the coinsurance for the bone marrow aspiration and the lab services. You say that 
you should not have to pay this much. 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 10% 
coinsurance for each in-network Medicare-covered surgery or other services provided in an outpatient hospital. 
Your contract with the Plan also clearly says that you must pay 10% coinsurance for in-network Medicare-
covered lab services. 
 
You have been asked to pay $246.89, which is 10% coinsurance of the allowed amount for the bone marrow 
aspiration ($2,468.92 allowed amount x 10% coinsurance = $246.89. This item/service falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities benefit category.  
 
You have also been asked to pay 10% coinsurance for the lab services. These items/services fall within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. 
 
Date of Service Code Allowed Amount 10% Coinsurance 
July 8, 2022 85025 $7.77 $0.78 
July 8, 2022 85045 $3.99 $0.40 
July 8, 2022 85097 $682.38 $68.24 
July 8, 2022 81305 $175.40 $17.54 
July 8, 2022 88305 $155.22 $15.52 
July 8, 2022 88161 $25.72 $2.57 
July 8, 2022 88184 $303.27 $30.33 
July 8, 2022 88237 $287.50 $28.75 
July 8, 2022 88262 $125.49 $12.55 
July 8, 2022 88366 $2,122.89 $212.29 
July 8, 2022 88313 $105.75 $10.58 
July 8, 2022 88342 $155.30 $15.53 
July 8, 2022 88365 $155.30 $15.53 
 
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 bone marrow aspiration and the laboratory services 
provided on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic and six retainer crowns. 
 
You asked the Plan to pre-approve the dental services. You say that you require eight crowns, and the Plan has 
only approved three. 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 authorization number A0230215128839. 
Therefore, we decided that the Plan does not have to pre-approve a pontic and six retainer crowns.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
May 14, 2022, to May 20, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you thought your 
copayment was $225 for this type of hospital visit. 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 $298 
copayment per day for days 1-7 of each inpatient hospital stay.  You have been asked to pay a $298 copayment per day for days 1-7 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have been asked to pay a total of 
$2,086 ($298 copayment per day x 7 days = $2,086). 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 inpatient hospital stay provided from May 14, 2022, to May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skin biopsy provided on October 13, 2022. 
 
You asked the Plan to pay for a skin biopsy. You say that this was medically necessary and should be covered. 
I have forwarded records for 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 a skin biopsy provided 
on October 13, 2022.