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

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

 
We decided that the Plan does not have to pay for an office visit provided on July 06, 2022, by an out-of-
network (OON) provider.  
 
 You asked the Plan to pay for an office visit. You say that you are requesting reconsideration asking for the 
enclosed medical records be reviewed. The Plan denied your request. The Plan says the enrollee must receive 
their care from a network provider (for more information about this, see Section 2 of Chapter 3). In most cases, 
care the enrollee receives from an out-of-network provider (a provider who is not part of the plans network) 
will not be 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 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 July 06, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic analysis of cochlear implant 
(92604) and the evaluation of auditory function for surgically implanted device(s) (92626) provided on May 5, 
2023. 
 
You asked the Plan to waive the copayment for a diagnostic analysis of cochlear implant (92604) and the 
evaluation of auditory function for surgically implanted device(s) (92626). You say that you paid the $30 for 
this visit at the time of the visit. You also say that the money has not yet been applied and now you are being 
told you owe $105. 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 Medicare covered hearing services in a specialist's office.  
 
You have been asked to pay a $30 copayment for a diagnostic analysis of cochlear implant (92604). This 
item/service falls within the Medicare covered hearing services in a specialist's office benefit category. You 
have also been asked to pay a $105 copayment for the evaluation of auditory function for surgically implanted 
device(s) (92626). This item/service falls within the outpatient hospital diagnostic procedures and tests 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 diagnostic analysis of cochlear implant 
(92604) and the evaluation of auditory function for surgically implanted device(s) (92626) provided on May 5, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the clinical documentation provided supports the 
medical necessity for IRF admission. The Plan denied your request. The Plan says  the enrollee's condition does 
not meet Medicare rules.  
 The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall, complicated by atrial fibrillation. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the medical records support a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a chemotherapy drug injection and the 
associated administration of the drug provided on July 28, 2022, provided by an OON provider. 
 You asked the Plan to reduce the copayment for a chemotherapy drug injection and the associated 
administration of the drug. You say that you disagree with the increased cost share applied to the injection 
received. 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 25% 
coinsurance for Medicare Part B chemotherapy drug injection and 25% coinsurance for the administration of 
the chemotherapy drug when provided by an OON provider.  
 
You have been asked to pay a total coinsurance of $1,278.50 for a chemotherapy drug injection and the 
associated administration of the drug. This total includes $1,259.42, which is 25% of the allowed amount for 
the chemotherapy drug injection ($5,037.70 allowed x 25% = $1,259.42), and $19.08, which is 25% of the 
allowed amount for the administration of the drug ($76.34 allowed x $25% = $19.08). This item/service falls 
within the Medicare Part B prescription drugs 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 chemotherapy drug injection and the associated administration of the drug provided on July 28, 2022, 
provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0230, D0220) provided on May 30, 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 November 17, 2021. 
Therefore, we decided that the Plan does not have to pay for intraoral x-rays (D0230, D0220) provided on May 
30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve outpatient visit. You say that you have been visiting this facility for 15 
years. The Plan denied your request. The Plan says the enrollee must receive their care from a network provider 
(for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an 
out-of-network provider (a provider who is not part of the plans network) will not be 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 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 visit to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on March 7, 2022. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the enrollee needed the 
ambulance because they could not walk at the time due to a reconstructed ankle. The Plan denied your request. The Plan says because the enrollee was admitted to a SNF as part of a covered rehabilitation stay at the time of 
the ambulance transport, the requested ambulance transport is covered under the enrollees part A stay. 
 
The Plan must follow Medicare rules. Medicare rules say that intra-campus transfers are not separately payable 
under the Part B ambulance benefit. We looked at the file and Medicare rules. The enrollee was admitted to a 
SNF as part of a covered rehabilitation stay at the time of the ambulance transport, the requested ambulance 
transport is covered under the enrollees part A stay. Based on this information, we decided that Medicare rules 
for coverage of the ambulance service and ground mileage have not been met. Therefore, we decided that the 
Plan does not have to pay for ambulance service, basic life support, non-emergency transport, and ground 
mileage provided on March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 9, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the lab services. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 the laboratory services provided on March 9, 
2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that  the dentist was listed as in-network. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided on May 
15, 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 28, 2023. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided 
on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames, photochromatic tint, anti-reflective coating, 
ultraviolet (U-V) lenses, progressive lenses, polycarbonate lenses, and miscellaneous vision items or services 
provided on February 6, 2023. 
 
You asked the Plan to pay for frames, photochromatic tint, anti-reflective coating, ultraviolet (U-V) lenses, 
progressive lenses, polycarbonate lenses, and miscellaneous vision items or services. You say that the glasses 
were purchased after cataract surgery. The Plan denied your request. The Plan says the requested services are 
not covered by Medicare or the Plan. 
 
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 eyeglasses or contact lenses after each cataract surgery that includes 
insertion of an intraocular lens. 
 
We looked at the file and the Plan's rules. The Plan rules say that one pair of eyeglasses or contact lenses are 
covered after each cataract surgery that includes insertion of an intraocular lens. The Plan rules also say that a 
routine eye examination is covered by the Plan every year. Frames and lenses are excluded from this benefit. 
The record shows that the eyeglasses were issued with a diagnosis of presbyopia and an astigmatism. 
Specifically, the record does not show that the eyeglasses were issued because of cataract surgery. Based on 
this information, we decided that the Plan's rules for coverage of frames, photochromatic tint, anti-reflective 
coating, ultraviolet (U-V) lenses, progressive lenses, polycarbonate lenses, and miscellaneous vision items or 
services have not been met. Therefore, we decided that the Plan does not have to pay for frames, 
photochromatic tint, anti-reflective coating, ultraviolet (U-V) lenses, progressive lenses, polycarbonate lenses, 
and miscellaneous vision items or services provided on February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you called the insurance company and were told the 
inserts would be covered with a 20% co-pay. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330) provided on June 5, 2023, to 
June 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like this to be covered. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for panoramic imaging (D0330) provided on June 5, 2023, to June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940 x 5), office 
visit provided by a chiropractor (99203) and electrical stimulation (G0283 x 5) provided from April 12, 2023, 
to April 21, 2023, by an out-of-network provider. 
 You asked the Plan to pay for the chiropractic services. You say that the chiropractic services have been 
helping you and should be a covered benefit. The Plan denied your request. The Plan says these chiropractic 
services are excluded from coverage, or the cost sharing was charged correctly. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 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 $70 copayment for each covered out-of-network 
chiropractic visit. 
 
The office visit and electrical stimulation at issue are not manual manipulation of the spine. You have also been 
asked to pay a $28.39 copayment for each chiropractic manipulative treatment because the allowed amount for 
this service is less than your contractual $70 copayment. This item/service falls within the Chiropractic 
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 pay for the chiropractic manipulative treatments 
(98940 x 5), office visit provided by a chiropractor (99203) and electrical stimulation (G0283 x 5) provided 
from April 12, 2023, to April 21, 2023, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee lives alone without available support 
and needs this care. The Plan denied your request. The Plan says the medical records do not show a need for 
SNF care.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee doesn't have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee doesn't have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee 
doesn't require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-ray, panoramic radiographic image, 2D oral/facial 
photographic image, oral hygiene instructions, and scaling in presence of generalized moderate or severe 
gingival inflammation (D0210, D0350, D1330, D4346, D0330) provided on April 5, 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 intraoral 
x-ray, panoramic radiographic image, 2D oral/facial photographic image, oral hygiene instructions, and scaling 
in presence of generalized moderate or severe gingival inflammation (D0210, D0350, D1330, D4346, D0330) 
provided on April 5, 2023.