Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the destruction of a precancer skin growth 
provided on January 30, 2023. 
 
You asked the Plan to waive the copayment for the destruction of a precancer skin growth. You say that you do 
not understand the copayment applied to this 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 a $295 
copayment for in-network Medicare-covered surgery or other services provided at an outpatient hospital. 
 
You have been asked to pay a $295 copayment for the destruction of a precancer skin growth. This item/service falls within the in-network Medicare-covered surgery or other services 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 $207.32. Therefore, we 
decided that the Plan does not have to waive the copayment for the destruction of a precancer skin growth 
provided on January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 27, 2022. 
 
You asked the Plan to pay for an office visit. You say that you would like a 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 an office visit provided 
on December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit on February 28, 2023. 
 
You asked the Plan to waive the deductible for an office visit. You say that you want to appeal the amount 
being charged. 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 health and wellness education 
programs.  
 
The item or service you asked the Plan to waive the deductible for falls within the health and wellness 
education programs benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $1,000 deductible which applies to health and wellness education programs. This cost 
sharing is a contractual obligation that had not been met at the time an office visit was received on February 28, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for an office visit on February 
28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care provided from March 17, 2021, to April 
2, 2021. 
 
You asked the Plan to pay for the home health care. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The file submitted does not include an OASIS comprehensive 
assessment and visit notes for the billed dates of service. Therefore, we decided that the Plan does not have to 
pay for the home health care provided from March 17, 2021, to April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization administration for vaccines/Toxoids on 
October 19, 2022. 
 
You asked the Plan to pay for immunization administration for vaccines/Toxoids. You say that it is medically 
necessary. The Plan denied your request. The Plan says the requested service is not covered by Medicare. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
administration for vaccines/Toxoids. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
administration for vaccines/Toxoids. Therefore, we decided that the Plan does not have to pay for 
immunization administration for vaccines/Toxoids on October 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography services provided on February 16, 2023. 
 
You asked the Plan to pay for mammography services. You say that a retro-authorization 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 mammography services 
provided on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on January 18, 2023. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that the records provided support the 
services. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for hospital outpatient clinic 
visit provided on January 18, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit (99214) provided on December 7, 2022. 
 
You asked the Plan to pay for the office visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan did not articulate the reason for the denial. The plan did not cite the 
Medicare policy used to make the determination. Therefore, we decided that the Plan has to pay for an office 
visit (99214) provided on December 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 
February 10, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that it is the 
responsibility of the facility to obtain prior 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 home visit for the 
evaluation and management provided on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 31, 2023. 
 
You asked the Plan to pay for an office visit. You say that you would like a 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 an office visit provided 
on January 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network debridement procedure on 
the skin provided from January 19,2023, to March 2, 2023. 
 
You asked the Plan to waive the copayment for an in-network debridement procedure on the skin. You say that 
this cost is too high, and you 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 a $295 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
There were 6 procedures, resulting in a $1,770 total copayment ($295 x 6 = $1,770). You have been asked to pay a $1,770 total copayment for an in-network debridement procedure on the skin. 
This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers 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 in-network debridement procedure on the skin provided from January 19,2023, to March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network laboratory service provided 
on April 7, 2023. 
 
You asked the Plan to waive the copayment for an in-network laboratory service. You say that you should not 
have these copayments 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% 
coinsurance for outpatient diagnostic lab services.  
 
The allowed amount of this drug is $78.12., resulting in a coinsurance amount of $264.12 ($78.12. x 20% = 
$15.62). You have been asked to pay a $15.62 coinsurance for an in-network laboratory service. This item/service falls 
within the outpatient diagnostic lab 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 an in-network laboratory service provided on April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 24, 2022. 
 
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 February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on January 25, 2023. 
 
You asked the Plan to pay for oxygen equipment. You say that your oxygen equipment was starting to 
breakdown, therefore, you thought this would be covered due to 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 oxygen equipment 
provided on January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visits. You say that the in-network providers are a long drive from 
your house. The Plan denied your request. The Plan says you must receive your 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visits to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthopedic services (27197) provided on January 1, 2023. 
 
You asked the Plan to pay for the orthopedic services. You say that this service was medically necessary. 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 February 1, 2023. 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 the orthopedic services have not been met. 
Therefore, we decided that the Plan does not have to pay for orthopedic services (27197) provided on January 
1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on August 04, 2022. 
 
You asked the Plan to pay for laboratory testing. 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 laboratory testing 
provided on August 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote physiologic monitoring provided on February 28, 
2023, by an out-of-network (OON) provider.  
 
 You asked the Plan to pay for remote physiologic monitoring. You say that are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 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 remote physiologic monitoring provided on 
February 28, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Treatment (96365, 96366, 
96521, J1817) provided on March 24, 2023. 
 
You asked the Plan to pay for Outpatient Intravenous Insulin Treatment. You say that this service was 
medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services comprising an Outpatient Intravenous 
Insulin Therapy regimen are nationally non-covered. 
 
We looked at the file and Medicare rules. The service performed is non-covered under Medicare rules. Based 
on this information, we decided that Medicare rules for coverage of Outpatient Intravenous Insulin Treatment have not been met. Therefore, we decided that the Plan does not have to pay for Outpatient Intravenous Insulin 
Treatment (96365, 96366, 96521, J1817) provided on March 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body (D6010) for teeth 
numbers 4, 6, 8, 10 and 12 provided on March 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dentist in this network created the need for 
this entire situation and caused you to have to remove your permanent teeth in order to obtain implants. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for surgical placement of implant body (D6010) for teeth numbers 4, 6, 8, 10 and 12 provided on March 
14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six office consultations and treatment to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve six office consultations and treatment. You say that you need to have this 
surgery as your sight is fading quickly. You also say that the requested provider is the only ophthalmologist 
located near you. The Plan denied your request. The Plan says the requested provider is not in-network. The 
Plan also says there are glaucoma specialists much closer. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
six office consultations and treatment to be provided by an out-of-network (OON) provider.