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

 
We decided that the Plan does not have to pay for the office visit (99202) and the excision of a lesion of 
mucosa and submucosa, vestibule of mouth; with simple repair (40812) rendered by the out-of-network (OON) 
provider on June 21, 2023.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization.  
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99202) and the excision of a lesion of mucosa and submucosa, 
vestibule of mouth; with simple repair (40812) rendered by the out-of-network (OON) provider on June 21, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on April 24, 2023. 
 
You asked the Plan to pay for x-rays. You say that 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 x-rays provided on April 
24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ear, nose, and throat (ENT) 
office visit provided on June 19, 2023. 
 
You asked the Plan to waive the copayment for an in-network ear, nose, and throat (ENT) office visit. You say 
that you thought this was a free hearing screening visit, you didnt even know this appointment was going to 
happen. 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 $30 
copayment for Physician/Practitioner services, including doctors officevisits. 
 
You have been asked to pay a $30 copayment for an in-network ear, nose, and throat (ENT) office visit. This 
item/service falls within the Physician/Practitioner services, including doctors officevisits 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 ear, nose, and throat (ENT) office visit 
provided on June 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
from May 31, 2022, to June 17, 2022. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you have paid 
over the amount for these bills, you do not understand where this money has gone.  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 $395 
copayment per day, for days 1 to 5 for inpatient mental health care.  
 
You were in the hospital for 5 days, resulting in a $1,975 total copayment (5 x $395 = $1,975). 
 You have been asked to pay a $1,975 total copayment for an in-network acute inpatient stay. This item/service 
falls within the inpatient mental health care 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 acute inpatient stay provided from May 31, 2022, to June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a mental health visit provided on June 6, 
2023. 
 
You asked the Plan to waive the deductible for a mental health visit. You say that the benefit summary says 
that there is no member liability. 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 $675 deductible which applies to outpatient mental health care.  
 
The enrollee has been asked to pay $94.45 towards their deductible for the mental health visit. The item or 
service you asked the Plan to waive 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 $675 
deductible which applies to outpatient mental health care. This cost sharing is a contractual obligation that had 
not been met at the time a mental health visit was received on June 6, 2023. Therefore, we decided that the Plan 
does not have to waive the deductible for a mental health visit provided on June 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 10, 2023, to 
June 2, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan must follow Medicare rules. The rules say the HHA enters a date of admission matching the From 
date on the first period of care in an admission. On subsequent periods of care, the HHA continues to submit 
the admission date reported on the first period of care. 
 We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the required 
data element, admission/start of care date on the subsequent period of care claim does not match the admission 
date reported on the first period of care NOA claim. Therefore, we decided that the Plan does not have to pay 
for the home health services provided from May 10, 2023, to June 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on March 13, 2023. 
 
You asked the Plan to waive the copayment for CT scan. You say that you say that you should not be assessed 
a copayment for the CT scan as it should have been covered as preventative with your medical and family 
history of having cancer. 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for CT scan. 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. Therefore, we decided that the Plan does not have to waive the 
copayment for CT scan provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 08, 2023. 
 
You asked the Plan to pay for the home 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 home visit provided 
on March 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on May 10, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 home visit evaluation 
provided on May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision of benign lesion (D7410) provided on June 1, 2023. 
 
You asked the Plan to pay for D7410. You say that you needed this dental work. The Plan denied your request. 
The Plan says the rendered dental work is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for excision 
of benign lesion (D7410) provided on June 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 19, 
2023, through January 20, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.   
 
 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that after the emergency department (ED) treatment, the enrollee was admitted to an inpatient 
status for a diagnosis of Coumadin toxicity, accidental or unintentional. The admitting history and physical 
exam assessment included a supratherapeutic international normalized ratio (INR) blood test, acute kidney 
injury, and hypertensive urgency. The plan of care included intravenous fluids, serial INR blood tests, 
continued home medication Nadolol, initiated Hydralazine, held home coumadin, Triamterene and 
Hydrochlorothiazide, and a social worker consult for consideration of the managing of home medications. The 
following day, there was no further bleeding and she discharged home on January 20, 2023. The review has 
determined that the record did not show that at the time of the inpatient admission it was reasonable for the 
admitting physician to expect that the enrollees necessary hospital care (including earlier emergency 
department (ED) and/or observation care) would span two midnights with supporting documentation of the 
enrollee's history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from January 19, 2023, through January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for frames (V2020), sphere single plano lenses (V2100), 
and polycarbonate lenses (V2784) provided on May 25, 2023. 
 
You asked the Plan to reimburse for frames (V2020), sphere single plano lenses (V2100), and polycarbonate 
lenses (V2784). You say that you appreciate the prompt attention for this claim. The Plan denied your request. 
The Plan says there was no prior authorization request for out-of-network provider's service. 
 
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 these services when you get prior authorization for out-of-network covered services. 
 
We looked at the file and the Plan's rules. The Plan rules say that authorization rules apply for out-of-network 
covered services. The record shows no prior authorization was obtained for these services. Based on this 
information, we decided that the Plan's rules for coverage of frames (V2020), sphere single plano lenses 
(V2100), and polycarbonate lenses (V2784) have not been met. Therefore, we decided that the Plan does not 
have to reimburse for frames (V2020), sphere single plano lenses (V2100), and polycarbonate lenses (V2784) 
provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal orthotic device, by report (D7880) provided on 
March 22, 2023. 
 
You asked the Plan to pay for the occlusal orthotic device. You say that you paid out-of-pocket and are 
requesting reimbursement as you believe this should be a covered benefit. The Plan denied your request. The 
Plan says non-routine dental services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
occlusal orthotic device, by report (D7880) provided on March 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex peripheral venous exam provided on May 04, 2023. 
 
You asked the Plan to pay for a duplex peripheral venous exam. You say that our patients need a specific kind 
of visit as they cannot leave their residence. This is also 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 duplex peripheral 
venous exam provided on May 04, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings (L8499, A6549). 
 
You asked the Plan to pre-approve compression stockings. You say that the items 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. Medicare rules say that wound care items are covered when specific 
criteria are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of compression stockings have not been met. Therefore, we decided that the Plan does not have to 
pre-approve compression stockings (L8499, A6549).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 29, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you say that you didnt have an 
ultrasound. 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 $15 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $15 copayment for an ultrasound. 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. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 11, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary for this patient to be 
seen. 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 May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mouth guard (D9944) provided on July 5, 2023. 
 
You asked the Plan to pay for D9944. You say that the enrollee is worried about fracturing her teeth. The Plan 
denied your request. The Plan says the denied service is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a mouth 
guard (D9944) provided on July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiology visit provided on April 25, 2023. 
 
You asked the Plan to pay for a cardiology visit. 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 a cardiology visit 
provided on April 25, 2023.