Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroacoustic hearing aid evaluation (92594) and the 
hearing aid check (92592) provided on December 13, 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 the services are not payable as they were not 
rendered by the Plans select hearing aid provider.  
 
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.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the hearing aid services provided in this case were 
not rendered by the Plans select hearing aid provider. Therefore, we decided that the Plan does not have to pay 
for the electroacoustic hearing aid evaluation (92594) and the hearing aid check (92592) provided on  
December 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray provided on December 17, 
2022. 
 
You asked the Plan to waive the copayment for the chest x-ray. You say that you just had a doctors visit and 
should only have to pay $5. 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 $100 
copayment for in-network outpatient x-rays provided at an outpatient hospital. 
 
You have been asked to pay a $100 copayment for the chest x-ray. This item/service falls within the in-network 
outpatient x-rays provided 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. However, since the allowed amount is less than the standard 
copayment, you only owe $83.11. Therefore, we decided that the Plan does not have to waive the copayment 
for the chest x-ray provided on December 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 12, 2022. 
 
You asked the Plan to pay for the 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 the laboratory services 
provided on October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental work provided on December 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that this was a covered benefit. 
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 March 23, 2023. 
Therefore, we decided that the Plan does not have to pay for dental work provided on December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on July 26, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that the supplies should not require 
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 the wound care supplies 
provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis (D1110) provided on October 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this service should be covered in full. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for prophylaxis (D1110) provided on October 
20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator device 
provided on December 21, 2022. 
 
You asked the Plan to waive the coinsurance for the automatic external defibrillator device. You say that you 
were not told about this coinsurance amount and cannot afford it. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the automatic external defibrillator device. This item/service 
falls within the durable medical equipment and related 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. The total you owe is $616.19 ($3,080.95 allowed 
amount x 20% coinsurance = $616.19). Therefore, we decided that the Plan does not have to waive the 
coinsurance for the automatic external defibrillator device provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an out-of-network specialist office visit provided on 
December 9, 2022. 
 
You asked the Plan to pay for an out-of-network specialist office visit. You say that you are in-network and 
should receive the full payment amount for this visit. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. Both the provider and facility are out-of-network. 
 
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 $1600 deductible for Physician/Practitioner services, including doctors office visits, before the 
Plan is required to pay out-of-network providers.  
 The enrollee has been asked to pay a $1600 deductible for an out-of-network specialist office visit. This 
item/service falls within the Physician/Practitioner services, including doctors office visits 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 pay for an out-of-network specialist office visit provided on December 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a house or extended care facility call (D9410) provided on 
October 5, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the house or 
extended care facility call is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a house or 
extended care facility call (D9410) provided on October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) for tooth #14 
provided on January 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that crowns were covered in 2022 and the notice of 
change you were sent did not address crowns not being covered. The Plan denied your request. The Plan says 
the denial of payment for these services is correct, because the crown and core buildup are not covered by the 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740) and core buildup (D2950) for tooth #14 provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for protective restoration (D2940) provided on December 8, 
2022. 
 
You asked the Plan to pay for protective restoration. 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 protective 
restoration (D2940) provided on December 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 17, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance crew came and assisted you with the insulin and got you some orange juice. You also say that after 
an hour your vitals were back to normal and decided you did not need to be transported. The Plan denied your 
request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 17, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on July 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on July 22, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical technicians checked your vital signs and reassured you that your oxygen levels and blood 
pressure were okay and that you only had a mild fever. You also say that you opted to stay home as your wife 
could not come and there was an 8 hour back-up in the emergency room. The Plan denied your request. The 
Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 22, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 19, 2023. 
 
You asked the Plan to pay for the office visit. You say that the records provided support medical necessity. 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 office visit provided 
on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet joint injection. 
 
You asked the Plan to pre-approve a lumbar facet joint injection. You say that a lumbar facet joint injection is 
medically necessary. The Plan denied your request. The Plan says the requested lumbar facet joint injection 
does not meet the Medicare LCD coverage criteria. The Plan says that the Plan did not receive information 
about the effectiveness of previous lumbar facet joint injections. 
 
The Plan follows Medicare rules. 
 
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 a lumbar facet joint injection. Our 
reviewer says that the requested lumbar facet joint injection is not considered medically necessary in this case. 
Our physician reviewer found that in this case, there is no documentation that previous facet joint injections 
provided a minimum of 80% relief of primary pain. There is no documentation that subsequent therapeutic 
facet joint procedures at the same anatomic site resulted in at least consistent 50% pain relief for at least three 
(3) months from the prior therapeutic procedure, or at least 50% consistent improvement in the ability to 
perform previously painful movements and activities of daily living as compared to baseline measurements 
using the same scale. The review has determined that the requested lumbar facet joint injections do not meet 
the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar facet joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lumbar facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on January 4, 2023, by an OON 
provider. 
 
You asked the Plan to pay for podiatry services. You say that you are requesting the denied claim be 
reprocessed. The Plan denied your request. The Plan says that the podiatry services were not authorized and are 
not covered by an OON 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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for podiatry services provided on January 4, 2023, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
December 06, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have to 
pay for a specialist since you already knew what the problem was. 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 the 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 the specialist office visit provided on December 06, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a SNF stay provided from April 21, 2022, to May 20, 2022. 
 
You asked the Plan to pay for the SNF stay. You say that you are asking for reconsideration of the denied 
claim. The Plan denied your request. The Plan says that this service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that prior authorization maybe required for SNF care. 
 
The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for a SNF stay provided 
from April 21, 2022, to May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on September 23, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that the enrollee does not have a choice on which 
provider they see. 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 September 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on November 18, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that this service was provided during an 
inpatient stay. 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 $60 
copayment for out-of-network outpatient diagnostic x-rays. 
 
You have been asked to pay a $60 copayment for the x-ray. This item/service falls within the out-of-network 
outpatient diagnostic x-rays 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. The records show this service was provided as an outpatient service from an out-of-
network provider. Therefore, we decided that the Plan does not have to waive the copayment for the x-ray 
provided on November 18, 2022.