Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on January 10, 2023, to 
March 30, 2023. 
 
You asked the Plan to pay for physical therapy services. 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 physical therapy 
services provided on January 10, 2023, to March 30, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on April 26, 2023. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you say please see the attached 
supporting documents proving medical necessity. 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 skilled nursing facility 
care provided on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 02, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered 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 August 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on July 14, 2023. 
 
You asked the Plan to pay for the chiropractic services. 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 chiropractic services 
provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care provided on July 07, 2023. 
 
You asked the Plan to pay for the chiropractic care. 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 chiropractic care 
provided on July 07, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
February 04, 2023, to February 06, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
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 $225 
copayment for inpatient hospital care. 
 
You have been asked to pay a $225 copayment for inpatient hospital care. 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. The total amount you owe is $450 ($225 x 2 days = $450). Therefore, we decided that the 
Plan does not have to waive the copayment for inpatient hospital care provided on February 04, 2023, to 
February 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulation provided on June 13, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the chiropractic manipulation. You say that you are requesting reconsideration of 
the denied claim. 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 the chiropractic manipulation provided on June 
13, 2023, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 31, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services should be covered. 
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 subsequent nursing 
facility care provided on March 31, 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 on July 
06, 2022, to July 27, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
fully covered. 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 $245 
copayment for inpatient hospital care. 
 
You have been asked to pay a $245 copayment for the inpatient hospital stay. 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. You have been asked to pay a total of $1,225 for the inpatient hospital stay ($245 
copayment x 5 days = $1,225). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on July 06, 
2022, to July 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on April 13, 2023, by an 
OON provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the nursing facility care provided on April 13, 2023, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on June 20, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the 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 $145 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $145 copayment for an ultrasound. 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 $107.24. Therefore, we decided that the Plan does not have to waive the copayment 
for an ultrasound provided on June 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 16, 2023. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services 
provided on May 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on May 24, 
2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
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 $275 
copayment for outpatient surgery. 
 
You have been asked to pay a $275 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery 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 $245.14. 
Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided 
on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each dialysis treatment provided on March 
02, 2023, to March 25, 2023. 
 
You asked the Plan to waive the coinsurance for each dialysis treatment. You say that you say that you dont 
agree with the copay assessed for dialysis services. 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 services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for each dialysis treatment. This item/service falls within the 
services to treat kidney disease 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 $759.11 ($345.07 allowed amount x 20% = $69.01 
{$69.01 coinsurance x 11 visits = $759.11}). Therefore, we decided that the Plan does not have to waive the 
coinsurance for each dialysis treatment provided on March 02, 2023, to March 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 24, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. 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 subsequent nursing 
facility care provided on July 24, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic colonoscopy 
provided on June 08, 2023. 
 
You asked the Plan to waive the copayment for an in-network diagnostic colonoscopy. You say that you feel 
this should be a screening procedure. No one informed you that this was not a screening colonoscopy or that 
there would be a large 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 $400 
copayment for outpatient surgery, including services provided athospital outpatient facilities and ambulatory 
surgicalcenters.  
You have been asked to pay a $400 copayment for an in-network diagnostic colonoscopy. This item/service 
falls within the outpatient surgery, including services provided athospital outpatient facilities and ambulatory 
surgicalcenters 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 an in-network diagnostic 
colonoscopy provided on June 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on July 19, 2023. 
 
You asked the Plan to pay for the podiatry services. 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 podiatry services 
provided on July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you should not have to pay for this. 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 May 10, 2023. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from June 2, 2023, to June 
3, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you are unable to afford the cost applied. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from June 2, 2023, to June 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on June 
15, 2023. 
 You asked the Plan to pay for a determination of refractive state (92015). You say that this service was not paid 
by the Plan, and you want to know why. The Plan denied your request. The Plan says the service is not covered 
under your contract under any normal circumstances. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for a determination of refractive state (92015) provided on June 15, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft, biologic materials to aid in soft and 
osseous tissue regeneration, soft tissue graft procedure, and intravenous moderate (conscious) 
sedation/analgesia (D4263, D4277, D4265, D5982. D9239, D9243) provided on August 14, 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 a bone 
replacement graft, biologic materials to aid in soft and osseous tissue regeneration, soft tissue graft procedure, 
and intravenous moderate (conscious) sedation/analgesia (D4263, D4277, D4265, D5982. D9239, D9243) 
provided on August 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service April 22, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99284 is bundled into 
payment for code 99291. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99284 
is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99284 billed for date of service April 22, 2023.