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

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 12, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you felt fine and wanted to 
drive yourself to the hospital but the medics did not want you to drive. 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 ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the ambulance 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 ambulance services 
provided on June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee benefited from BiPAP in a hospital setting and would likely require continued BiPAP. There was 
no failure of BiPAP or escalation required. There is no indication for a home ventilator per best practice 
recommendations given the documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital observation 
provided on July 14, 2023. 
 
You asked the Plan to waive the copayment for the outpatient hospital observation. You say that you want to 
appeal the amount being 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 a $325 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $325 copayment for the outpatient hospital observation. This item/service falls 
within the outpatient hospital observation 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. However, since the allowed amount is less than the standard copayment, 
you only owe $109.14. Therefore, we decided that the Plan does not have to waive the copayment for the 
outpatient hospital observation provided on July 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on July 31, 
2023. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you had not had a 
copayment related to an annual physical exam in the past. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for an electrocardiogram. 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. However, since the allowed amount is less than the 
standard copayment, you only owe $16.37. Therefore, we decided that the Plan does not have to waive the 
copayment for an electrocardiogram provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, and debridement of nails provided on August 
15, 2023. 
 
You asked the Plan to pay for a home visit, and debridement of nails. 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 a home visit, and 
debridement of nails provided on August 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Gammagard (J1569). 
 
You asked the Plan to pre-approve Gammagard. You say that Gammagard is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says Gammagard is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Gammagard. Our reviewer says that the 
requested drug is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that the provided medical records document hypogammaglobulinemia with recurrent bacterial infections in the 
setting of multiple myeloma. However, the records do not document subprotective antibody levels after 
immunization against diphtheria, tetanus or pneumococcal infection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gammagard have not been met. Therefore, we decided that the Plan does not 
have to pre-approve treatment with Gammagard (J1569).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility care provided on March 30, 2023. 
 
You asked the Plan to pay for the skilled nursing facility care. You say that you say that 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 the skilled nursing 
facility care provided on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 06, 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 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lenses (V2783), progressive lenses (V2781), and anti-
reflective coating (V2750) provided on July 27, 2023. 
 
You asked the Plan to pay for lenses (V2783), progressive lenses (V2781), and anti-reflective coating (V2750). 
You say that you were under the impression that your lenses would be covered according to what the provider 
told you. The Plan denied your request. The Plan says the benefit for lenses (V2783) and progressive lenses 
(V2781) have been exhausted. The Plan also says that anti-reflective coating (V2750) is not covered.  
 
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 one pair of standard frames and lenses every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one pair of standard lenses 
and frames every year. The Plan rules also say that options that are not covered include upgraded progressive 
lenses, blended bifocal, hi index, tinting, scratch coating, ultra-violet (UV) or anti-reflective coating, and 
polycarbonate. The record shows the benefit for the lenses (V2783) and the progressive lenses (V2781) was 
exhausted on July 6, 2023. Anti-reflective coating (V2750) is not a covered benefit under this Plan. Based on 
this information, we decided that the Plan's rules for coverage of lenses (V2783), progressive lenses (V2781), 
and anti-reflective coating (V2750) have not been met. Therefore, we decided that the Plan does not have to 
pay for lenses (V2783), progressive lenses (V2781), and anti-reflective coating (V2750) provided on July 27, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on July 14, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that having a 
procedure authorized should mean she does not have to pay for it. 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 the computed tomography (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. However, since the allowed amount is 
less than the standard copayment, you only owe $90.59. Therefore, we decided that the Plan does not have to 
waive the copayment for the computed tomography (CT) scan provided on July 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 10, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that the 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 wound care supplies 
provided on August 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on April 22, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that this copayment is very 
expensive and you would appreciate if the copayment could be waived 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 ambulance services. 
 
You have been asked to pay a $325 copayment for ambulance services. This item/service falls within the ambulance 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 ambulance services 
provided on April 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
July 1, 2023, through July 12, 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 psychiatric hospital care 
provided was not medically necessary.  
 
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 pay for these service. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for acute inpatient psychiatric hospitalization on June 14, 2023 with 
Schizoaffective Disorder, Unspecified Type. Based upon the review of the records provided, it was not 
expected that this enrollee would improve in a reasonable period of time beyond the dates in question as he was 
not showing any dangerousness to self or others, or auditory and visual hallucinations, and was without 
aggressive behaviors while not showing any acute threats to safety. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory and visual 
hallucinations, or abnormal behaviors. The health plans denial of continued inpatient psychiatric services 
appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in 
question as noted above as he was not a danger to himself or others and did not have any delusions, or auditory 
and visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It 
did not appear that the services for the dates in question were reasonably expected or medically necessary to 
improve the enrollees condition or were for the purpose of a diagnosis. This enrollee was treated under an 
individualized treatment plan; however, the entire record was not provided. It appears that the services were 
supervised and evaluated by a physician. Based upon the review of the records provided, this enrollee does not 
meet the criteria for coverage of the acute inpatient mental health treatment provided beyond the date in 
question of July 1, 2023 forward and could have been treated in a lesser restrictive setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric hospital care provided from July 1, 2023, through July 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 30, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were transferred to a 
skilled nursing facility from the hospital. You are appealing this cost sharing. 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 $55.00 
copayment for ambulance services. 
 
You have been asked to pay a $55.00 copayment for ambulance services. This item/service falls within the ambulance 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 ambulance services 
provided on May 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomographic angiography (CTA) 
with 3D image postprocessing provided on July 28, 2023. 
 
You asked the Plan to waive the copayment for computed tomographic angiography (CTA) with 3D image 
postprocessing. You say that you should not be responsible to pay this because your provider said they were 
unable to get a good reading. 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 advanced imaging.  
You have been asked to pay a $225 copayment for computed tomographic angiography (CTA) with 3D image 
postprocessing. This item/service falls within the advanced imaging 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 computed tomographic angiography (CTA) with 3D image postprocessing 
provided on July 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 17, 
2023. 
 
You asked the Plan to pay for the limited oral evaluation. The Plan denied your request. The Plan says this 
service is not covered under your 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial comprehensive physical exam (99387) provided on 
May 2, 2023. 
 
You asked the Plan to pay for the physical exam. You say that you were not aware that a physical exam by 
your primary physician and your female gynecological exam would be classified as the same type of physical 
exam. You say that the exams were different and necessary. You also say that  The Plan denied your request. 
The Plan says the benefit for this service has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that plans must pay for a medical service or item if regular 
Medicare would pay for it in this case. 
 
Based on review of the file, an annual physical exam was provided less than 12 months prior to the visit at 
issue in this case. Therefore, we decided that the Plan does not have to pay for the initial comprehensive 
physical exam (99387) provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided on June 22, 2023. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you have to pay out of pocket 
for the exam because the plan paid the provider for an exam he did not do. You also say that just your tooth 
was extracted. The Plan denied your request. The Plan says your benefit for the requested comprehensive oral 
evaluation 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 service was exhausted on date of service June 9, 2023. The Plan has 
provided evidence that an oral exam was provided on June 9, 2023. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided on June 
22, 2023.  
 
Your complaint about the exam not performed by the provider is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.