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

 
We decided that the Plan does not have to pay for remote patient monitoring provided on July 28, 2023. 
 
You asked the Plan to pay for remote patient monitoring. You say that this provider was the only provider 
available to render the services. 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 remote patient 
monitoring provided on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on July 21, 2023. 
 
You asked the Plan to pay for a home visit. You say that you are requesting reconsideration for the denied 
claim. 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 home visit provided on 
July 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rechargeable battery hearing aids. 
 
You asked the Plan to pre-approve rechargeable battery hearing aids. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says they require you to contact the Plan hearing 
specific provider to arrange your hearing related services. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you go through the Plan hearing specific provider to schedule your appointments for 
hearing examinations and hearing aids.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of rechargeable battery hearing aids have not been met. Therefore, we decided that the Plan does not 
have to pre-approve rechargeable battery hearing aids.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the lab testing on June 13, 2023.  
 
You asked the Plan to waive the deductible for the lab testing. You say that you would like the medical records 
to be reviewed and the claim to be reprocessed and paid. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,300 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,300 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
the lab testing was received on June 13, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for the lab testing on June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home ventilator provided on July 16, 2022. 
 
You asked the Plan to pay for the home ventilator. 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 the home ventilator 
provided on July 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on May 02, 2023, to May 30, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are requesting reconsideration of the denied 
claim. 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 home visit provided 
on May 02, 2023, to May 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says this service is available with in-network providers. 
 
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 OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on February 27, 2023. 
 
You asked the Plan to pay for scaling in presence of generalized moderate or severe gingival inflammation. 
You say that this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 scaling in 
presence of generalized moderate or severe gingival inflammation (D4346) provided on February 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network outpatient hospital 
services provided on June 15, 2023. 
 
You asked the Plan to waive the coinsurance for out-of-network outpatient hospital services. You say that you 
disagree with the coinsurance. 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 40% 
coinsurance for out-of-network outpatient hospital services/surgery services. 
 
You have been asked to pay 40% coinsurance for out-of-network outpatient hospital services. This item/service 
falls within the out-of-network outpatient hospital services/surgery 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 coinsurance for out-of-network outpatient hospital services provided on June 15, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on July 27, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 August 3, 2021. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided 
on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rides. 
 
You asked the Plan to pre-approve additional rides. You say that you were hit from behind at a traffic light. 
You also say your car has been towed to the nearest auto body location, so you are without transportation for an 
unknown amount of time. The Plan denied your request. The Plan says your Plan only covers 24 one-way trips. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional rides.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve preventive medicine service to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve preventive medicine service. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says this provider is out-of-
network, and the service could be performed in-network. 
 
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 
preventive medicine service 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 waive the copayment for a Medicare Part B drug injection and 
specialist visit provided on June 14, 2023. 
 
You asked the Plan to waive the copayment for a Medicare Part B drug injection and specialist visit. You say 
that you disagree with the cost share applied for the injection required for the enrollee's treatment. 
 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 20% coinsurance for Medicare Part B prescription drugs a $30 copayment for services performed by 
a specialist.  
 
The enrollee has been asked to pay $290.51 for a Medicare Part B drug injection and specialist visit. This total 
includes $13.67, which is less than the standard copayment for a specialist visit, and $276.84 coinsurance, 
which is 20% of the allowed amount for a Medicare Part B chemotherapy drug injection ($1,384.20 allowed x 
20% = $276.84). This item/service falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug injection and specialist visit 
provided on June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis adult (D1110) provided on July 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 August 25, 2022, and 
January 23, 2023. Therefore, we decided that the Plan does not have to pay for prophylaxis adult (D1110) 
provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on September 21, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you did not receive an 
electrocardiogram at your office 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on May 11, 2023. 
 
You asked the Plan to pay for the home visit. You say that you are requesting reconsideration of the denied 
claim. 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 home visit provided 
on May 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an outpatient surgery performed on May 18, 2023. 
 
You asked the Plan to waive the cost for an outpatient surgery. You say that you disagree with the cost share 
applied. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $600 deductible which applies to outpatient surgery and a $350 
copayment for outpatient surgery services performed at an outpatient hospital, after the deductible has been 
met.  
 
 You have been asked to pay $663.67 for an outpatient surgery. This total includes $502.08, which was the 
remaining amount needed to meet your deductible, and $161.59, which is less than the $350 copayment applied 
after meeting your deductible. The item or service you asked the Plan to waive the copayment for falls within 
the outpatient surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $600 deductible which applies to outpatient surgery. This cost sharing is a contractual 
obligation that had not been met at the time an outpatient surgery was received on May 18, 2023. Therefore, we 
decided that the Plan does not have to waive the cost for an outpatient surgery performed on May 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cataract surgery to be provided by an OON provider.  
 
You asked the Plan to pre-approve the cataract surgery. You say that you are requesting reconsideration of the 
denied service. The Plan denied your request. The Plan says the service was not approved. 
 
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 cataract surgery to be provided by an OON provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiologic examination, chest; 2 views provided at urgent care on  
July 13, 2023. 
 
You asked the Plan to pay for radiologic examination, chest; 2 views. You say that the patient was seen at an 
urgent care facility and the facility does not staff radiologists so this service was for the professional reading of 
the radiology. The Plan denied your request. The Plan says that the services rendered required prior 
authorization and there were network providers available. 
 
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 provided a Medicare rule or a Plan rule to 
substantiate that only in-network providers are required, under this PPO Plan, to obtain prior authorization for 
these services. Also, the Plan has not provided the network status of the urgent care center that provided the 
radiology services. Therefore, we decided that the Plan has to pay for radiologic examination, chest; 2 views 
provided at urgent care on July 13, 2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on May 30, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodontal maintenance (D4910) provided on May 30, 2023.