Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatments provided on December 
02, 2022, to December 19, 2022. 
 
You asked the Plan to pay for chiropractic manipulative treatments. You say that these services were 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 chiropractic 
manipulative treatments provided on December 02, 2022, to December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facet joint injection provided on December 20, 2022. 
 
You asked the Plan to pay for a facet joint injection. You say that this is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a facet joint injection 
provided on December 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for heart catheterization procedure provided on 
February 28, 2023. 
 
You asked the Plan to waive the copayment for heart catheterization procedure. You say that the test was 
unnecessary and you should not have to pay. 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 $325 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $325 copayment for heart catheterization procedure. This item/service falls within the in-network outpatient surgery, including services provided at hospital outpatient facilities 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 heart catheterization procedure provided on 
February 28, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a SNF stay provided from November 17, 
2022, to November 30, 2022. 
 
You asked the Plan to reduce the copayment for a SNF stay. You say that you were not informed the facility 
was out-of-network and the total cost you would be responsible for. 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 $225 
copayment per day for days 1 to 45 for out-of-network SNF care.  
 
 
  You have been asked to pay a $3,150 copayment for a SNF stay ($225 per day x 14 days = $3,150). 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 reduce the copayment for a 
SNF stay provided from November 17, 2022, to November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on September 29, 2022. 
 
You asked the Plan to pay for wound care 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 wound care services 
provided on September 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on June 8, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says in order for a facility to receive reimbursement for a 
Medicare member, the facility must be enrolled to participate in the Medicare program. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 26, 2023. 
 
You asked the Plan to pay for office visit. You say that you say that there is no reason that a referral from your 
primary care physician should be 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 office visit provided on 
January 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services provided on January 
25, 2023. 
 
You asked the Plan to waive the deductible for the lab services. You say that you should only have to pay a $5 
copayment for this 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. Your 
contract with the Plan says that there is a $400 deductible which applies to outpatient laboratory services. Your 
contract with the Plan also says that you pay a $0 copayment after meeting the deductible for outpatient 
laboratory services.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible which applies to outpatient laboratory services. This cost sharing is a 
contractual obligation that had not been met at the time the lab services was received on January 25, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the laboratory services provided 
on January 25, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on April 28, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the services rendered were 
medically necessary. The Plan denied your request. The Plan says enrollees must receive their care from a 
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on April 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 25, 2023. 
 
You asked the Plan to pay for an office visit. You say that you want this to be reconsidered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) for tooth #5 provided on December 
27, 2022. 
 You asked the Plan to pay for the dental service. You say that the Plan does not cover any dental related 
services. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
extractions are not covered by the Plan. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction (D7210) for tooth #5 provided on December 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the catheter and the medical supplies 
provided on January 17, 2023. 
 
You asked the Plan to waive the coinsurance for the catheter and the medical supplies. You say that you are 
being over charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each Medicare-covered prosthetic device. Your contract with the Plan also clearly says that you 
must pay 20% coinsurance for each Medicare-covered medical supply. You have been asked to pay $231.60, which is 20% coinsurance of the allowed amount for the catheter 
($1,158.00 allowed amount x 20% = $231.60).  You have also been asked to pay $2.88, which is 20% 
coinsurance of the allowed amount for the medical supplies ($14.40 allowed amount x 20% = $2.88). You have 
been asked to pay a total of $234.48 ($231.60 coinsurance + $2.88 coinsurance = $234.48). These 
items/services fall within the prosthetic devices and related 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 coinsurance for the catheter and the medical supplies provided on January 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on March 01, 2023. 
 
You asked the Plan to pay for x-rays. 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 
March 01, 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 
August 25, 2022, to September 2, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were waiting for 
approval for the rehabilitation, and you should not be charged for those extra days. 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 $215 
copayment per day, for days 1 to 7 and a $0 copayment per day, for days 8 to 90 for each Medicare-covered 
hospital stay.  
 You have been asked to pay a $215 copayment per day, for days 1 to 7 of the inpatient hospital stay. You have 
been asked to pay a total of $1,505 ($215 copayment x 7 days = $1,505). 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 August 25, 2022, to 
September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aflibercept injections, and an intravitreal injection provided 
on January 09, 2023. 
 
You asked the Plan to pay for aflibercept injections, and an intravitreal injection. You say that these services 
were 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 aflibercept injections, 
and an intravitreal injection provided on January 09, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 5, 2022, to 
August 20, 2022. 
 
You asked the Plan to pay for home health services. You say that you submitted supporting documentation for 
reconsideration. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 5, 2022. The NOA was not received by the Plan until September 9, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 5, 2022, to August 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), core buildup (D2950), and the endodontic 
therapy (D3320) for tooth #4 provided on December 27, 2022, and December 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know the cost was going to be so 
high or else you would have not agreed to the amount. The Plan denied your request. The Plan says the denial 
of payment for these services is correct, because crowns, core buildup, and the endodontic therapy are not 
covered by the Plan. 
 
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 crown 
(D2740), core buildup (D2950), and the endodontic therapy (D3320) for tooth #4 provided on December 27, 
2022, and December 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 23, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that after 
having preformed standard protocol the ambulance crew suggested that you should go to the hospital. You also 
say that the problem being that the hospital's close by were over crowed in the emergency room so you were 
taken to a hospital by your husband to a not out of your area of travel. The Plan denied your request. The Plan 
says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 23, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 10, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and should be 
covered. You had a referral. 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). There was no referral or prior authorization (which is different than a referral) found 
for this service. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on 
November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the acupuncture services provided form 
January 5, 2023, to February 2, 2023. 
 
You asked the Plan to provide reimbursement for the acupuncture services. You say that you were told you 
would get reimbursed $74.94. 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 $45 
copayment for each acupuncture service.  
 
You have been asked to pay a $37.47, for each service, which is less than the standard $45 copayment. This 
item/service falls within the acupuncture services benefit category. Because the allowed amount is less than the standard copayment, you are not owed any reimbursement. 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 provide 
reimbursement for the acupuncture services provided form January 5, 2023, to February 2, 2023.