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

 
We decided that the Plan does not have to waive the copayment for a specialist office vist provided on July 31, 
2023. 
 
You asked the Plan to waive the copayment for a specialist office vist. 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 $35 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $35 copayment for a specialist office vist. This item/service falls within the 
physician/practitioner services/specialist 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 a specialist office vist provided on July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an over bed table. 
 
You asked the Plan to pre-approve an over bed table. You say that you would like this table so that you can 
have your breakfast in the morning. You said that it takes you a long time to get out of bed, and you really need 
this table. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that over bed tables are not covered.  Although this 
item may be helpful for you, neither the Plan nor Medicare covers this item.  Therefore, we decided that the 
Plan does not have to pre-approve an over bed table.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and prophylaxis (D1110) 
provided on July 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed these dental services. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 January 13, 2023, and 
April 21, 2023. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120), and prophylaxis (D1110) provided on July 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray provided on July 20, 2023. 
 
You asked the Plan to waive the copayment for the chest x-ray. You say that the chest x-ray should be apart of 
the overall health check and not billed separately. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $60 copayment for the chest x-ray. This item/service falls within the 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. However, since the allowed amount is less than the standard 
copayment, you only owe $39.83. Therefore, we decided that the Plan does not have to waive the copayment 
for the chest x-ray provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the therapeutic injections provided on 
May 19, 2023, by an OON provider.  
 
You asked the Plan to pay for the office visit and the therapeutic injections. You say that you say that the 
service was medically necessary. The Plan denied your request. The Plan says the 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 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 the office visit and the therapeutic injections 
provided on May 19, 2023, by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health visit provided on June 05, 2023. 
 
You asked the Plan to pay for the mental health 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 mental health visit 
provided on June 05, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on June 28, 2023. 
 
You asked the Plan to pay for physical therapy. 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 physical therapy 
provided on June 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammogram provided on July 06, 2023. 
 
You asked the Plan to waive the copayment for a mammogram. 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 $59 
copayment for outpatient diagnostic tests/diagnosticprocedures and tests. 
 
You have been asked to pay a $59 copayment for a mammogram. This item/service falls within the outpatient 
diagnostic tests/diagnosticprocedures and tests 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 a mammogram provided on July 06, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 19, 2023, to June 
22, 2023. 
 
You asked the Plan to pay for the home health services. You say that you believe that the Type of Bill code 
billed was correct. The Plan denied your request. The Plan says you billed this claim with an incorrect Type of 
Bill code. 
 
The Plan must follow Medicare rules. Medicare rules say that the Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim).  
In this case, you billed the claim in dispute with Type of Bill code 322.  However, according to Medicare rules, 
you should have billed code 329. Please note that the rule that you referenced in your appeal letter is no longer 
valid- Medicare changed the rule regarding Type of Bill codes to be used in April of 2023 (Please see the 
citation referenced in the rules section above to locate the new Medicare rule.) 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from June 19, 2023, to June 22, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy, provided on April 11, 2023. 
 
You asked the Plan to pay for psychotherapy,. You say that this service is supported in the records proving 
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 psychotherapy, provided 
on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on August 03, 
2023. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you do not agree 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 $55 
copayment for each Medicare-covered urgently needed service at an urgent care center. 
 
You have been asked to pay a $55 copayment for an urgent care visit. This item/service falls within the each 
Medicare-covered urgently needed service at an urgent care center 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 an urgent care visit provided on August 03, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment from November 12, 2023 
- forward. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, this enrollee does not meet the criteria for November 12, 2023 forward as this enrollee 
was not shown to be a danger to herself or others. There were no delusions, auditory or visual hallucinations 
noted. She was cooperative/compliant with treatment while not showing any threats the safety as she waited 
placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment from November 12, 2023 - forward.
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 July 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency situation. 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 15, 2022, with the paid service D0330. Therefore, we decided that the Plan does not have to pay for a complete series of 
radiographic images (D0210) provided on July 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute hospital stay provided 
on June 26, 2023, to June 30, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute hospital stay. You say that this 
hospitalization was due to a surgical issue. You feel you should not be held liable for these copayments, the 
hospital should. 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 inpatient hospital services.  
You have been asked to pay a $225 copayment for an in-network acute hospital 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 total of $900 for the inpatient hospital stay ($225 
copayment x 4 days = $900). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network acute hospital stay provided on 
June 26, 2023, to June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5120) provided on June 30, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that this would 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 December 13, 2018. Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5120) provided on 
June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on April 26, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 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 the laboratory service provided on April 26, 2023, 
by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance angiogram provided on June 01, 2023. 
 
You asked the Plan to pay for a magnetic resonance angiogram. 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 a magnetic resonance 
angiogram provided on June 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 10 units of A7000 billed for date of service May 22, 2023. 
 
You asked the Plan to pay for 10 units of A7000. You say that these supplies were needed by the enrollee. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 26, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for 10 units of A7000 have not been met. Therefore, we decided that the Plan does not have to pay for 10 units of A7000 billed for date of service May 
22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles (A0170). 
 
You asked the Plan to pre-approve the additional miles. You say that you need the additional trips for 
upcoming and follow-up appointments. You also say that you don't have alternative transportation available. The Plan denied your request. The Plan says the service is a covered benefit, but the request will exceed the 
benefit limits set in the agreement for routine transportation. 
 
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 50 miles trips per year.  
 
We looked at your request, the records in the case file, and the rules. You are requesting a trip of 55 miles for a 
total of 105 miles. 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 routine transportation miles (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an injection and an ophthalmic imaging 
provided on June 27, 2023. 
 
You asked the Plan to waive the cost share for an injection and an ophthalmic imaging. You say that you were 
unaware of the cost share for the injections and feel you should have been informed prior to the service. 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 prescription drugs and a $20 copayment per day for Medicare-covered 
outpatient diagnostic tests.  
 
You have been asked to pay $395.29 coinsurance for an injection and an ophthalmic imaging. This total 
includes $375.29 coinsurance, which is 20% of the allowed amount for an injection ($1,876.46 allowed x 20% 
= $375.29) and a $20 copayment for ophthalmic imaging. An injection falls within the Medicare Part B 
prescription drugs benefit category. The imaging falls within the outpatient diagnostic tests 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 an injection and an ophthalmic imaging provided on June 27, 
2023.