Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on January 17, 
2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items at issue are not payable 
as they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract provides coverage for hearing aids 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids purchased on January 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on January 26, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were not 
notified that you would have a copayment for the MRI. 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 outpatient diagnostic test. 
 
You have been asked to pay a $225 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 $210.85, which is less than the standard $225 copayment 
for an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic 
resonance image (MRI) provided on January 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 19, 2023, to January 23, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you disagree with the 
inpatient hospital care charges. 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 per day, for days 1 to 7 and a $0 copayment per day, for days 8 to 90 for inpatient hospital care.  
 
 You have been asked to pay a $150 copayment per day, for days 1 to 4 of the inpatient hospital stay. You have 
been asked to pay a total of $600 ($150 copayment x 4 days = $600). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital 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 the inpatient hospital stay provided from January 19, 2023, to 
January 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the blood flow ultrasound provided on 
January 30, 2023. 
 
You asked the Plan to waive the copayment for the blood flow ultrasound. You say that you were not asked for 
a payment at the time of 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 $100 
copayment for outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $100 copayment for the blood flow ultrasound. This item/service falls within the 
outpatient diagnostic tests, including ultrasounds 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 the blood flow ultrasound provided on January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the cardiac stress test and medical supplies 
provided on January 23, 2023. 
 
You asked the Plan to waive the cost share for the cardiac stress test and medical supplies. You say that you 
were not told you had a deductible. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for in-network outpatient diagnostic radiology at a free-standing radiology clinic. Your contract 
with the Plan also clearly says that you must pay 20% coinsurance for in-network medical suppliles. 
 
You have not been charged a deductible. You have been asked to pay a $250 copayment for the cardiac stress 
test. You have also been asked to pay $213.06, which is 20% coinsurance of the allowed amount for the 
medical supplies ($1,065.30 allowed amount x 20% coinsurance = $213.06). These items/services fall within 
the outpatient diagnostic tests and therapeutic services benefit category. You have been asked to pay a total of 
$463.06 ($250 copayment + $213.06 coinsurance = $463.06). 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 the cardiac stress test and medical supplies provided on January 23, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on August 03, 2022, to August 25, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you were advised 
by the facility that you did not have to pay anything out-of-pocket and the Plan would cover the visit. 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 $25 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $25 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation service 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 each physical therapy (PT) visit provided on August 03, 2022, to August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a second opinion. You say that you want to see an out-of-network 
cardiologist for ongoing issues. The Plan denied your request. The Plan says there are many other in-network 
options that are available for you. 
 
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 second opinion to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, and the skin biopsies provided by an out-of-
network (OON) provider on January 4, 2023. 
 
You asked the Plan to pay for the office visit and the skin biopsies. You say that you did not think about 
whether these services would be covered. The Plan denied your request. The Plan says you generally must 
receive your care from a network provider. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the office visit, and the skin biopsies provided by an out-of-network (OON) provider on 
January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each physical therapy (PT) visit provided 
on December 14, 2022. 
 
You asked the Plan to waive the coinsurance for each physical therapy (PT) visit. You say that the 
authorization does not mention the requirement for a 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 outpatient rehabilitation service.  
You have been asked to pay 20% coinsurance for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation service 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 each physical therapy (PT) visit provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatments (98940) to be 
rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 services at issue in this appeal.   
 
We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that 
the Plan does not have to pre-approve chiropractic manipulative treatments (98940) to be rendered by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on September 20, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you should 
not be have been ordered and was not necessary. 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 $300 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $300 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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 $226.37, which is less than the standard $300 copayment 
for a CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 17, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services are 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 laboratory services 
provided on January 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a magnetic resonance image (MRI) 
provided on January 05, 2023. 
 
You asked the Plan to reduce the copayment for a magnetic resonance image (MRI). You say that your spouse 
had an MRI and only paid a $50 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 $100 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $100 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 copayment for a 
magnetic resonance image (MRI) provided on January 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the wound debridement services provided 
from November 21, 2022, to January 9, 2023. 
 
You asked the Plan to waive the copayments for the wound debridement services. You say that this did not 
happen in an operating room. 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 2022 contract with the Plan clearly says that you must pay a 
$290 copayment for each in-network outpatient hospital facility visit. Your 2023 contract with the Plan also clearly says that you must pay a $290 copayment for each in-network outpatient hospital facility visit. 
 
You have been asked to pay a $290 copayment for each wound debridement services. These items/services fall 
within the outpatient hospital services benefit category. You have been asked to pay a total of $1,740 ($290 
copayment per service x 6 services = $1,740). 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 copayments for the wound 
debridement services provided from November 21, 2022, to January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0856) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee needs a new 
power wheelchair for errands and other appointments. The Plan denied your request. The Plan says that a 
power wheelchair is not covered for outside use. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. As the power wheelchair base is not 
covered, the requested accessories are denied. Therefore, we decided that the Plan does not have to pre-approve 
a Group 3 power wheelchair (K0856) and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of torus palatinus (D7472) provided on 
December 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 
removal of torus palatinus (D7472) provided on December 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 96365 and 96366 provided on November 10, 2022. 
 
You asked the Plan to pay for procedure codes 96365 and 96366. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the records do not support 
the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 96365 is Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, 
up to 1 hour. The definition of code 96366 is Intravenous infusion, for therapy, prophylaxis, or diagnosis 
(specify substance or drug); each additional hour (List separately in addition to code for primary procedure). 
 
We find that CPT codes 96365 and 96366 are supported in the medical record. Specifically, the records show 
that the time over which the infusion was administered was 2 hours 22 minutes. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 96365 and 96366 have been met. Therefore, we 
decided that the Plan has to pay for procedure codes 96365 and 96366 provided on November 10, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental fillings, cleaning, and intraoral x-rays (D2392, D2393, 
D0140, D1110) provided on December 13, 2022, to December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $3,000 dental benefit maximum allowance 
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 September 6, 2022. 
Therefore, we decided that the Plan does not have to pay for dental fillings, cleaning, and intraoral x-rays 
(D2392, D2393, D0140, D1110) provided on December 13, 2022, to December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on December 21, 
2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you feel this was billed incorrectly. 
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 in-network vision care. 
 
You have been asked to pay a $30 copayment for the eye exam. This item/service falls within the in-network 
vision 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. The record shows this claim was approved and you are responsible for the cost share amount. Therefore, 
we decided that the Plan does not have to waive the copayment for the eye exam provided on December 21, 
2022.