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

 
We decided that the Plan does not have to pay for nursing facility care provided on November 30, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
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 November 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 17, 
2023, to January 18, 2023. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the enrollee no longer met the criteria for continued stay in a SNF.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from January 17, 2023, to January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a resin-based composite - four or more 
surfaces or involving incisal angle (anterior) (D2335) provided on February 15, 2023. 
 
You asked the Plan to waive the coinsurance for the resin-based composite. You say that these services should 
be covered. 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 Class 2 basic services.  
 
You have been asked to pay $51.64, which is 20% of the allowed amount for the resin-based composite. The 
allowed amount is $258.18 (20% x $258.18 = $51.64). The resin-based composite service falls within the Class 
2 basic 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 coinsurance for a resin-based composite - 
four or more surfaces or involving incisal angle (anterior) (D2335) provided on February 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Computed tomography (CT), thorax provided on March 10, 
2023. 
 
You asked the Plan to pay for Computed tomography (CT), thorax. You say that you are appealing the claim 
payment denial. 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 Computed tomography 
(CT), thorax provided on March 10, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for injections and specialist visits provided 
from October 7, 2022, to October 24, 2022. 
 
You asked the Plan to reduce the cost share for injections and specialist visits. You say that you feel the 
provider over charged you for the services rendered. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs and a $20 copayment for each specialist visit.  You have been asked to pay $139.14 for injections and specialist visits. This total includes $79.14 coinsurance 
for the injections ($26.38 per injection x 3 injections = $79.14) and a $60 copayment for the specialists visit 
($20 per visit x 3 visits = $60). This item/service falls within the Medicare Part B drugs benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the cost share for injections and specialist visits provided from October 7, 
2022, to October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for frames (V2020), progressive lenses (V2781), and  
polycarbonate lenses (V2784) provided on April 12, 2023. 
 
You asked the Plan to pay more for frames (V2020), progressive lenses (V2781), and  polycarbonate lenses 
(V2784). You say that you have a $125 allowance for eyewear services. You also say you would like the Plan 
to pay a total of $125 for the services received April 12, 2023. The Plan denied your request. The Plan says 
they reviewed your claim history and found that you received contact lenses on March 13, 2023. The Plan also 
says the benefit was exhausted with the current claim. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up a $125 allowance every calendar year towards the purchase of eyeglasses or 
contact lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan will provide reimbursement or a 
$125 allowance every calendar year towards the purchase of eyeglasses or contact lenses. The record shows 
that on March 13, 2023, the Plan paid $72.86 towards the purchase of contact lenses. The record also shows the 
Plan paid $52.14 towards this claim, thus exhausting the benefit. Based on this information, we decided that the 
Plan's rules for coverage of frames (V2020), progressive lenses (V2781), and  polycarbonate lenses (V2784) 
have not been met. Therefore, we decided that the Plan does not have to pay more for frames (V2020), 
progressive lenses (V2781), and  polycarbonate lenses (V2784) provided on April 12, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on December 14, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay an outpatient mental health visit. You say that the records provided support the 
services provided. The Plan denied your request. The Plan says these services can be obtained from an out of 
network (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 an outpatient mental health visit care from out-of-network providers only 
in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The provider at issue in this case is not a network provider with the Plan. 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 pay for an outpatient mental health visit an outpatient mental health visit.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an outpatient mental health visit have not been met.  
 
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 pay for an outpatient mental health visit. Therefore, we decided that 
the Plan does not have to pay an outpatient mental health visit provided on December 14, 2022, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service March 7, 
2023. 
 
You asked the Plan to pay for procedure code 20936. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 20936 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 08, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting a reconsideration of the denied 
charges. 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 08, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services (0012M) provided on December 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary and should be 
covered. The Plan denied your request. The Plan says that the out-of-network service was not pre-authorized. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the lab services by a contract provider. The file does not show that the plan 
provided notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for lab services (0012M) 
provided on December 29, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on November 30, 
2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were not advised the copayment 
would be $275, but thought it would only be the $35 specialist 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 20% 
coinsurance for Medicare Part B Prescription Drugs. 
 
You have been asked to pay 20% coinsurance for an injection. This item/service falls within the Medicare Part 
B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The total you owe is $249.16, which is 20% of the allowed amount for a Medicare Part B 
drug injection ($1,245.81 allowed x 20% = $249.16). Therefore, we decided that the Plan does not have to 
waive the coinsurance for an injection provided on November 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on April 1, 2019, to April 30, 
2019. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the provider is not Medicare certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for home health services provided on April 
1, 2019, to April 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29580 billed for date of service April 4, 
2023.  
 
You asked the Plan to pay for procedure code 29580. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29580 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 29580 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 29580 billed for date of service April 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan and Medicare do not cover fully electric hospital beds. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CTA to be provided at an OON facility.  
 
You asked the Plan to pre-approve a CTA to be provided at an OON facility. You say that you do not agree 
with the denial for the requested service. The Plan denied your request. The Plan says the service can be 
provided at an in-network facility. 
 
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 
a CTA to be provided at an OON facility.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the laboratory service coded as U0003 and U0005 provided 
on March 11, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for  the laboratory service. You say that pursuant to an order from the enrollee's 
medical provider, you performed a diagnostic COVID-19 test utilizing high throughput technology The Plan 
denied your request. The Plan says independent physician association (IPA)/physician-hospital organization 
(PHO) has financial responsibility. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has that the 
IPA/PHO has financial responsibility. As the secondary insurer, the Plan cannot be held responsible for the 
laboratory service until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for  the laboratory service coded as U0003 and U0005 provided on March 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bifocal lens (V2200), tinting (V2745), fundus photography 
(92250), and frames (V2020) provided on March 9, 2023. 
 
You asked the Plan to pay for bifocal lens (V2200), tinting (V2745), fundus photography (92250), and frames 
(V2020). You say that the last time you got glasses, both pairs were covered. The Plan denied your request. 
The Plan says you already received the covered frames and lens package for this service. Therefore, this benefit 
has been exhausted. The Plan also says that fundus photography is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $300 benefit toward the purchase and fitting of eyeglasses (one per calendar year). 
Fundus photography is not a covered benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say they will cover a $300 benefit toward the purchase 
and fitting of eyeglasses (one per calendar year). Fundus photography is not a covered benefit. The record 
shows that fundus photography is not a covered benefit (92250). The record also shows that for the bifocal lens 
(V2200), tinting (V2745) and frames (V2020) benefit has already been exhausted on this same date of service. 
Based on this information, we decided that the Plan's rules for coverage of bifocal lens (V2200), tinting 
(V2745), fundus photography (92250), and frames (V2020) have not been met. Therefore, we decided that the 
Plan does not have to pay for bifocal lens (V2200), tinting (V2745), fundus photography (92250), and frames 
(V2020) provided on March 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve Mounjaro. You say that Mounjaro is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mounjaro.   
Benefits for Mounjaro 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field assessment (0379T) provided on January 18, 
2023. 
 
You asked the Plan to pay for a visual field assessment (0379T). You say that the physician determined the test 
was medically necessary in determining the best course of treatment. 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 visual field assessment 
(0379T) provided on January 18, 2023.