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

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
January 05, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. 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 a home visit for the 
evaluation and management provided on January 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the drug injection and drug administration 
provided on January 23, 2023. 
 
You asked the Plan to reduce the coinsurance for the drug injection and drug administration. You say that you 
were told this procedure would be $225. 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 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the drug injection and drug administration. 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 reduce the coinsurance for 
the drug injection and drug administration provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the specialist office visit, the fluoroscopic 
guidance procedure, and the triamcinolone injection provided on February 1, 2023.  
 
You asked the Plan to reduce the cost share for the specialist office visit, the fluoroscopic guidance procedure, 
and the injection. You say that you were charged incorrectly. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for services from a specialist. Your contract with the Plan also clearly says that you must pay a 
$110 copayment for Medicare-covered radiological diagnostic services. Your contract with the Plan also 
clearly says that you must pay 20% coinsurance for Medicare-covered Part B drugs. 
 
You have been asked to pay a $25 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category.  You have also been asked to 
pay a $110 copayment for the fluoroscopic guidance procedure. This item/service falls within outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. 
 
You have also been asked to pay $0.87, which is 20% coinsurance of the allowed amount for the injection 
($4.36 allowed amount x 20% = $0.87). This item/service falls within the Medicare Part B prescription 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 reduce the cost share for the specialist office visit, the 
fluoroscopic guidance procedure, and the triamcinolone injection provided on February 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 24, 2023. 
 
You asked the Plan to pay for laboratory 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 laboratory services 
provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health services provided on 
January 06, 2021. 
 
You asked the Plan to waive the copayment for the mental health services. You say that you have full coverage. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for outpatient mental health care. 
 
You have been asked to pay a $25 copayment for the mental health services. This item/service falls within the 
outpatient mental health 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 the mental 
health services provided on January 06, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 21, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for 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 office visit provided on 
November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on February 20, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 nursing facility visit 
provided on February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist office visit provided on 
September 22, 2022, and the endoscopy procedure provided on September 29, 2022. 
 You asked the Plan to waive the deductible for the specialist office visit and the endoscopy procedure. You say 
that you disagree with the charges. 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 $1,000 deductible which applies to the specialist office visit and the 
endoscopy procedure. Your contract with the Plan also clearly says that you must pay 50% coinsurance for out-
of-network services obtained from a specialist. Your contract with the Plan also clearly says that you must pay 
50% coinsurance for out-of-network Medicare-covered surgery. 
 
You have been asked to pay $204.66 towards your deductible for the specialist office visit. The item or service 
you asked the Plan to waive the deductible for falls within the physician/practitioner services, including 
doctors office visits benefit category. You have also been asked to pay $170.85 towards your deductible for 
the endoscopy procedure. The item or service you asked the Plan to waive the deductible for falls within the 
outpatient surgery and other medical services provided at ambulatory surgical centers. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to 
physician/practitioner services, including doctors office visits and outpatient surgery and other medical 
services provided at ambulatory surgical centers. This cost sharing is a contractual obligation that had not been 
met at the time the specialist office visit and the endoscopy procedure. was received on September 22, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for the specialist office visit provided 
on September 22, 2022, and the endoscopy procedure provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 05, 2023, to January 16, 
2023. 
 
You asked the Plan to pay for an office visit. You say that the provider is in-network. 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 January 05, 2023, to January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (CMT) provided on 
January 02, 2023. 
 
You asked the Plan to pay for chiropractic manipulative treatment (CMT). You say that the services should be 
covered. 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 
manipulative treatment (CMT) provided on January 02, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit, and the inpatient 
hospital stay provided from January 14, 2023, to January 18, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit, and the inpatient hospital stay. You 
say that you are on a fixed income. 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 $95 
copayment per visit for emergency care, and a $250 copayment per day, per admission, days 1-7 for each 
inpatient hospital stay. 
 
You have been asked to pay a $95 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. You have also been asked to pay a $1000 copayment for the inpatient 
hospital stay ($250 x 4 days = $1000). 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 the emergency room visit, and the inpatient 
hospital stay provided from January 14, 2023, to January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7210, D7140) provided on April 3, 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 services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 
extractions (D7210, D7140) provided on April 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence panel provided on January 
21, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the targeted genomic sequence panel. You say that this service was 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 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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the targeted genomic sequence panel provided on January 21, 
2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient rehabilitation stay provided 
from January 26, 2023, to February 4, 2023. 
 
You asked the Plan to reduce the copayment for an inpatient rehabilitation stay. You say that the services 
should be covered because your copayment maximum is $275. 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 $275 
copayment per day for days 1 to 5 and $0 copayment after day 5 for inpatient hospital care.  
 
 You have been asked to pay $1,375 for an inpatient rehabilitation stay ($275 per day x 5 days = $1,375). 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 reduce the 
copayment for an inpatient rehabilitation stay provided from January 26, 2023, to February 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377) 
and a transfer handle (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you insist that you need the wheelchair 
and all requested accessories to feel safe in your home, transport yourself to the doctor and live a healthy life. 
The Plan denied your request. The Plan says Medicare Guidance says that transfer handles do not serve a 
medical purpose and cannot be covered. The upgraded electronics (expandable controller, harness and 
electronic connector to 2 power options) are not medically necessary. They cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found per SSA 1862 (a)1(A) as you have adequate upper body strength and function to 
manage standard power drive controls, the requested accessories are not necessary to meet your needs. The 
transfer handles are not a covered item as they do not serve a medical purpose. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311), a harness (E2313), an expandable controller (E2377) and a transfer handle 
(K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy services provided on December 20, 2022. 
 
You asked the Plan to pay for chemotherapy services. You say that this was medically necessary and should be 
covered. 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 chemotherapy services 
provided on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided from January 
5, 2023, to February 15, 2023. 
 
You asked the Plan to pay for the outpatient mental health services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says a LMFT is ineligible to enroll 
in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 The services you received in this case were provided by a Licensed Marriage and Family Therapist (LMFT). 
This provider type is not eligible to enroll in Medicare. No provider shall receive payment for services 
furnished to a Medicare beneficiary unless the provider is enrolled in the Medicare program. Therefore, we 
decided that the Plan does not have to pay for the outpatient mental health services provided from January 5, 
2023, to February 15, 2023.