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

 
We decided that the Plan does not have to pay for an office visit provided on July 14, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
Please review and reprocess. 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 July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided 
on August 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that there was a limitation for 
these x-rays. 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 June 8, 2022. Therefore, we decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided 
on August 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on June 16, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on June 16, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 6, 2023. 
 
You asked the Plan to pay for the physician's services. You say that these services are not covered under 
hospice. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on July 6, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy telehealth services provided on July 17, 2023. 
 
You asked the Plan to pay for psychotherapy telehealth services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained as required under 
the Plan benefits.  
 
The Plan contract says the Plan covers certain telehealth services. The enrollee has the option of getting these 
services through an in-person visit or by telehealth. The enrollee must use a network provider who offers the 
service by telehealth 
 
We looked at the file and the Plans rules. The file shows the provider is not a network provider. Based on this 
information, we decided that Plans rules for coverage of psychotherapy telehealth services have not been met. 
Therefore, we decided that the Plan does not have to pay for psychotherapy telehealth services provided on 
July 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-ray services provided on August 17, 
2023. 
 
You asked the Plan to waive the copayment for X-ray services. You say that you disagree with the copayment. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient diagnostic tests/Medicare-coveredX-rays. 
 
You have been asked to pay a $20 copayment for X-ray services. This item/service falls within the outpatient 
diagnostic tests/Medicare-coveredX-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. Therefore, we decided that the Plan does not have to waive the copayment 
for X-ray services provided on August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on July 13, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. 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 hospital outpatient 
clinic visit provided on July 13, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the mental health visit provided on August 
3, 2023. 
 
You asked the Plan to reduce the deductible for the mental health visit. You say that you would like for the 
claim to be reprocessed at the in-network benefit level. 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 $725 deductible which applies to out-of-network outpatient mental 
health care.  
 
 
 You have been asked to pay $108.31 towards your $725 deductible for the mental health visit. The item or 
service you asked the Plan to reduce the deductible for falls within the outpatient mental health care benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $725 
deductible which applies to outpatient mental health care. This cost sharing is a contractual obligation that had 
not been met at the time the mental health visit was received on August 3, 2023. Therefore, we decided that the 
Plan does not have to reduce the deductible for the mental health visit provided on August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination provided on August 14, 2023. 
 
You asked the Plan to pay for radiologic examination. 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 radiologic examination 
provided on August 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99284) provided on June 15, 
2023. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim is not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code 99284 is not supported in the medical record. Specifically, the record shows the 
enrollee was incarcerated and the claim was not billed using the required QJ modifier. Based on this 
information, we decided that Medicare rules for coverage of the emergency room services have not been met. 
Therefore, we decided that the Plan does not have to pay for emergency room services (99284) provided on 
June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap), and administration provided on March 31, 2023. 
 
You asked the Plan to pay for the immunization services. You say that the enrollee was not aware that this 
would have been covered had they received the vaccine at the pharmacy. The Plan denied your request. The 
Plan says these services are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization 
services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and 
acellular pertussis vaccine (Tdap), and administration provided on March 31, 2023.  
 
Benefits for the immunization services may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit evaluation provided on June 26, 2023. 
 
You asked the Plan to pay for the home visit evaluation. 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 the home visit 
evaluation provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 15, 2022. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services 
provided on December 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient rehabilitation stay 
provided on June 01, 2023, to June 09, 2023. 
 
You asked the Plan to waive the copayment for an in-network inpatient rehabilitation stay. You say that you 
thought you were at a skilled nursing facility, not another hospital. This bill is too 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 a $250 
copayment for inpatient hospital services. 
 
You have been asked to pay a $250 copayment for an in-network inpatient rehabilitation stay. This item/service falls within the inpatient hospital 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. You have been asked to pay a $250 copayment for the inpatient hospital 
admission. Therefore, we decided that the Plan does not have to waive the copayment for an in-network 
inpatient rehabilitation stay provided on June 01, 2023, to June 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the cone beam CT capture and interpretation with 
field of view of both jaws; with or without cranium, removal of torus mandibularis, deep sedation/general 
anesthesia  first 15-minutes and deep sedation/general anesthesia  each subsequent 15-minute increment 
provided on August 9, 2022, and September 15, 2022. 
 
You asked the Plan to reimburse you for dental services. You say that you would like to be reimbursed for the 
services you received. Also, you thought you could get all the services paid for under your medical coverage 
instead of dental. The Plan denied your request. The Plan says these services are not covered under your 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. Cone beam CT capture and 
interpretation with field of view of both jaws; with or without cranium, removal of torus mandibularis, deep 
sedation/general anesthesia  first 15-minutes and deep sedation/general anesthesia  each subsequent 15-
minute increment are not covered under the Plans dental benefits. 
 
You may also be asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 
 
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 reimburse you for 
the cone beam CT capture and interpretation with field of view of both jaws; with or without cranium, removal 
of torus mandibularis, deep sedation/general anesthesia  first 15-minutes and deep sedation/general anesthesia 
 each subsequent 15-minute increment provided on August 9, 2022, and September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 09, 2023. 
 
You asked the Plan to pay for the office 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 office visit provided 
on July 09, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 12, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on July 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventative care services provided on April 11, 2023. 
 
You asked the Plan to pay for the preventative care services. 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 preventative care 
services provided on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient diagnostic tests and medical 
supplies provided on July 20, 2023. 
 
You asked the Plan to waive the cost share for outpatient diagnostic tests and medical supplies . You say that 
you disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 
copayment or outpatient diagnostic tests/Medicare-covered outpatient diagnostic procedure and a 20% 
coinsurance for outpatient diagnostic tests/Medicare-covered supplies.  You have been asked to pay a $175 copayment for outpatient diagnostic tests and a 20% coinsurance for 
medical supplies. The total allowed amount for the medical supplies is $2,088. You are being asked to pay 
$417.60 ($2,088 x 20% = $417.60). The total amount you are being asked to pay is $592.60 ($175 + $417.60 = 
$592.60). This item/service falls within the outpatient diagnostic tests/Medicare-covered outpatient diagnostic 
procedure/Medicare-covered 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. Therefore, we decided that the Plan does not have to waive the cost share for 
outpatient diagnostic tests and medical supplies provided on July 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the ostomy supplies provided on July 11, 
2023. 
 
You asked the Plan to reduce the coinsurance for the ostomy supplies. You say that you were unaware of the 
providers network status. 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 50% 
coinsurance for out-of-network durable medical equipment and related supplies. 
 
You have been asked to pay 50% coinsurance for the ostomy supplies. This item/service falls within the out-of-
network 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. Therefore, we decided that the Plan does not have to reduce 
the coinsurance for the ostomy supplies provided on July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 15, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on August 15, 2023.