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

 
We decided that the Plan does not have to waive the coinsurance for a chemical agent used in a positron 
emission tomography (PET) scan provided on February 16, 2023. 
 
You asked the Plan to waive the coinsurance for a chemical agent used in a positron emission tomography 
(PET) scan. You say that the service was for a PET scan and you paid the $50 copayment but the provider 
billed the IV Glucose in addition to the PET scan. 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 diagnostic test. 
 
You have been asked to pay 20% coinsurance for a chemical agent used in a positron emission tomography (PET) 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 $71.73, which is 
20% of the allowed amount for Medicare-covered medical supply ($358.69 x 20% = $71.73). Therefore, we 
decided that the Plan does not have to waive the coinsurance for a chemical agent used in a positron emission 
tomography (PET) scan provided on February 16, 2023.
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 December 30, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the summary 
of benefits showed that you pay $0 for diagnostic radiology. 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 $175 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $175 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 $172.50, which is less than the standard 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 December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810) provided on  
September 13, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not payable as it was not 
rendered on the basis of a covered diagnosis.   
 
 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture service have not been met. Specifically, the acupuncture service in this case was not rendered 
on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not have to pay 
for the acupuncture treatment (97810) provided on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 1, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 1, 2023, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient therapy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve outpatient therapy. You say that the member would like to continue 
psychiatrist services. The Plan denied your request. The Plan says in-network providers are available to provide 
these 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 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 
outpatient therapy to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the comprehensive cardiac evaluation 
provided on February 10, 2023. 
 
You asked the Plan to waive the coinsurance for the comprehensive cardiac evaluation. You say that you 
cannot afford this coinsurance. 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 in-network outpatient diagnostic tests provided by an outpatient hospital. 
 
You have been asked to pay 20% coinsurance for the comprehensive cardiac evaluation. This item/service falls 
within the in-network outpatient diagnostic tests provided by 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. The total you owe is 
$4,501.88 ($22,509.38 allowed amount x 20% coinsurance = $4,501.88). Therefore, we decided that the Plan 
does not have to waive the coinsurance for the comprehensive cardiac evaluation provided on February 10, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral - periapical 
first radiographic image (D0220), provided on March 12, 2023. 
 
You asked the Plan to pay for D0140 and D0220. You say that these services are routine. The Plan denied your 
request. The Plan says the rendered dental services are not covered 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 a limited 
oral evaluation (D0140), and intraoral - periapical first radiographic image (D0220), provided on March 12, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for miscellaneous vision item or service (V2799) and high 
index lenses (V2782) purchased on February 28, 2023. 
 You asked the Plan to reimburse for miscellaneous vision item or service (V2799) and high index lenses 
(V2782). You say that your new eyeglasses are required due to cataract surgery you had in January 2023. The 
Plan denied your request. The Plan says upgraded lenses are not covered under the medical vision benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that high index glass or plastic (V2782) for 
indications such as light weight or thinness will be denied as a non-covered deluxe feature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of miscellaneous vision item or service (V2799) and high index lenses (V2782) have not been met. 
Therefore, we decided that the Plan does not have to reimburse for miscellaneous vision item or service 
(V2799) and high index lenses (V2782) purchased on February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary partial dentures (D5525) provided on March 7, 
2023. 
 
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 maxillary 
partial dentures (D5525) provided on March 7, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from July 26, 2022, to 
September 4, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the enrollee needed to be in the 
facility for the dates of service billed and the stay was approved. 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 $0 
copayment for days 1 to 20 and a $188 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay a $3,948 copayment for a SNF stay ($188 per day x 21 days = $3,948). This 
item/service falls within the SNF 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 a 
SNF stay provided from July 26, 2022, to September 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a paraffin wax bath provided on June 12, 2022. 
 
You asked the Plan to pay for a paraffin wax bath. You say that you have found that wax treatments are helpful 
in alleviating your pain. The Plan denied your request. The Plan says this is non-covered service. 
 
  The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for OTC items. Medicare 
rules also say that Plans may offer as a supplemental benefit health-related items and medications that are 
available without a prescription, and are not covered by Medicare. If the primary purpose of the item or service 
is comfort, cosmetic or daily maintenance, then it is not eligible as a supplemental benefit. Convenience and 
comfort items, as well as cosmetic items (such as skin moisturizers) are specifically listed as not being eligible 
for a supplemental OTC benefit.  
 
We looked at the file and Medicare rules and the Plan rules. Medicare rules say that Convenience and comfort 
items, as well as cosmetic items (such as skin moisturizers) are specifically listed as not being eligible for a 
supplemental OTC benefit. Therefore, a paraffin wax bath is not a covered benefit. Based on this information, 
we decided that Medicare rules for coverage of a paraffin wax bath  have not been met. Therefore, we decided 
that the Plan does not have to pay for a paraffin wax bath provided on June 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 10, 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 November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image provided on March 23, 
2023. 
 
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 benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 9, 2022. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image provided on 
March 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on January 19, 2021, 
to January 21, 2023.  
 
You asked the Plan to waive the copayment for inpatient hospital stay . You say that you cannot afford this 
payment. 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 per day for days 1-3inpatient hospital stay. There were two days. 2 x $250 = $500. Therefore, 
resulsts in the total cost sharing amount of $500.   
 
 
 You have been asked to pay a $250 copayment per day for inpatient hospital stay. This item/service falls within 
the inpatient 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. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital 
stay on January 19, 2021, to January 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for electrocardiogram (EKG) on April 05, 
2023.  
 
You asked the Plan to waive the copayment for EKG. You say that the EKG should be covered under your 
office visit copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each type of Medicare-covered EKG following the Welcome to Medicare Visit. Covered 
services include but are not limited to other outpatient diagnostic tests. The provider billed in the amount of 
$71 and the allowed amount is $14.39. This is less than the copayment amount. Therefore, results in the total 
cost sharing amount of $14.39.  You have been asked to pay a $14.39 copayment, which is less than the copayment for EKG. 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 electrocardiogram (EKG) on April 05, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospitalization - 
inpatient detox. 
 
You asked the Plan to pre-approve continued inpatient psychiatric hospitalization. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued inpatient psychiatric 
hospitalization. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of July 14, 2023, forward and could have been 
treated in a lesser restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, delusions and was not showing any behaviors or aggression. He was being cooperative and 
compliant while not showing any acute threats to safety. The enrollee's vitals appear stable and there is no 
documented Clinical Institute Withdrawal Assessment (CIWA) score. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric hospitalization have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient psychiatric hospitalization - inpatient 
detox.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy (PT) evaluation 
provided on March 01, 2023, to March 02, 2023. 
 
You asked the Plan to waive the copayment for a physical therapy (PT) evaluation. You say that you do not 
feel you should have to pay for the physical therapy evaluation because the therapist came into your room, said 
it doesnt look like you needed therapy and left. 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 $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for a physical therapy (PT) evaluation. This item/service falls within the outpatient rehabilitation 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. The total you owe is $35, which is less than the standard copayment for a 
PT service. Therefore, we decided that the Plan does not have to waive the copayment for a physical therapy 
(PT) evaluation provided on March 01, 2023, to March 02, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay from March 2, 2023, through 
March 29, 2023.  
 
You asked the Plan to waive the copayment for SNF stay. You say that you were told there would be no 
copayment if you were discharged on the 29th, so that is why you left on that day. 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 for days 1-20 $0 
copayment per day and days 21-100 $196 copayment per day. Prior authorization is required for some services 
by your doctor or other network provider. You have been asked to pay a total of $1,372 for the SNF stay ($196/day x 7 days = $1,372). The SNF stay 
falls within the skilled nursing facility (SNF) 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 SNF stay from March 2, 2023, through March 29, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy visits provided on 
November 21, 2022, to January 16, 2023. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you are appealing the cost-
share 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 $15 
copayment for each in-network and out-of-network comprehensive outpatient rehabilitation facility (CORF) 
visit. 
 
  You have been asked to pay a total of  $45 for physical therapy visits ($15 copayment x 3 visits - $45). 
Physical therapy falls within the outpatient rehabilitation 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 the physical therapy visits provided on November 21, 2022, to January 16, 2023.