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

 
We decided that the Plan does not have to pay for an office visit provided on May 30, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration asking to please 
reconsider. 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 May 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on May 27, 2023, and 
May 31, 2023, by an out-of-network (OON) provider.  
  You asked the Plan to pay for the home health services. You say that it is the facilities responsibility to obtain a 
prior authorization and the services rendered were necessary. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no approved authorization. Also, the services rendered 
were not urgent or emergent. 
 
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 home health services provided on May 27, 
2023, and May 31, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99347 provided on May 8, 2023. 
 
You asked the Plan to pay for procedure code 99347. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Per Medicare coding guidelines, procedure code 99347 can be billed with place 
of service code 33. The Plan has not provided any Medicare rules or regulations to support that the place of service billed is not payable with procedure code 99347. Therefore, we decided that the Plan has to pay for 
procedure code 99347 provided on May 8, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) and a determination of a 
refractive state (92015) provided on April 4, 2023.  
You asked the Plan to pay for a medical eye examination (92014) and a determination of a refractive state 
(92015). You say that the rendering provider does not take your insurance, so you would like to be reimbursed 
for the costs of the examination. The Plan denied your request. The Plan says this benefit has been exhausted. 
 
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 these services  once every 12 months. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one eye examination every 12 
months. Based on this information, we decided that the Plan's rules for coverage of a medical eye examination 
(92014) and a determination of a refractive state (92015) have not been met. Therefore, we decided that the 
Plan does not have to pay for a medical eye examination (92014) and a determination of a refractive state 
(92015) provided on April 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network electrocardiogram (EKG) 
provided on June 14, 2023. 
 
You asked the Plan to waive the copayment for an in-network electrocardiogram (EKG). You say that you do 
not feel you should have to pay for this test. 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 $10 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for an in-network electrocardiogram (EKG). This item/service 
falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an in-network electrocardiogram (EKG) provided on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 16, 2023, to March 13, 
2023, by an OON provider.  
 
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 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 office visit provided on January 16, 2023, to 
March 13, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast biopsy provided on May 25, 2023. 
 
You asked the Plan to waive the copayment for a breast biopsy. You say that you object to the procedure being 
billed as surgery. 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 $375 
copayment for in-network surgery services provided at an outpatient hospital. 
 
You have been asked to pay a $375 copayment for a breast biopsy. This item/service falls within the in-
network surgery services provided at an outpatient hospital benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a breast biopsy provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the intraoral radiographic images (D0220 
and D0230) and the bitewings (D0272) provided on June 15, 2023. 
  You asked the Plan to waive the copayment for the dental services. You say that you were never told by the 
provider that you would owe a copayment for the dental x-rays. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. Also, it was verified that prior to the date of service you were advised 
of the proper dental benefits and copayments. 
 
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 $15 
copayment for x-rays.  
 
You have been asked to pay a $15 copayment for each of the dental x-rays. This item/service falls within the 
dental services 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 intraoral radiographic 
images (D0220 and D0230) and the bitewings (D0272) provided on June 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for extremity brace provided on May 26, 
2023. 
 
You asked the Plan to waive the coinsurance for extremity brace. You say that you say that there is no way a 
sling could cost this much. 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 durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for extremity brace. This item/service falls within the durable 
medical equipment (DME) 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. The total you owe is $168.58 ($842.90 allowed amount x 20% = 
$168.58). Therefore, we decided that the Plan does not have to waive the coinsurance for extremity brace 
provided on May 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a bone growth stimulator to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
a bone growth stimulator to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth consultation provided on July 03, 2023. 
 
You asked the Plan to pay for the telehealth consultation. 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 telehealth 
consultation provided on July 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an adult prophylaxis (D1110) and an intraoral, 
periapical x-ray (D0220) provided on June 22, 2023. 
 
You asked the Plan to pay more for the dental services. You say that it appears that all fees were denied on the 
basis that your dentist was not part of the Plan dental network. The Plan denied your request. The Plan says you 
are responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider.  
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for an adult prophylaxis (D1110) and an 
intraoral, periapical x-ray (D0220) provided on June 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88305, 88341, and 88342 provided on 
January 4, 2023. 
 
You asked the Plan to pay for procedure codes 88305, 88341, and 88342. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says two of the billed diagnosis 
codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that K29.00 has an Excludes1 note in relation to K25.9. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for procedure codes 88305, 88341, and 88342 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 88305, 88341, and 88342 provided on January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eyeglasses.  
 You asked the Plan to pre-approve eyeglasses. You say that you lost your eyeglasses and need them to be 
replaced. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
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 up to $200 for either eyeglasses or contact lenses once every 2 years. 
 
We looked at the file and the Plan's rules. Specifically, you received contact lenses within the past 2 years. 
Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pre-approve eyeglasses.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
May 06, 2023. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you disagree with 
the air mileage charge. 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 an ambulance transportation. 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 an 
ambulance transportation provided on May 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 17, 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 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown repair (D2980) provided on July 12, 2023. 
 
You asked the Plan to pay for crown repair. You say that this should be covered. The Plan denied your request. 
The Plan says this is not a covered service. 
 
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 crown 
repair (D2980) provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
May 12, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the services denied correctly as payment has already been 
made for 3 units. 
 
The Plan must follow Medicare rules. Medicare rules say that billing more than 1 unit of service per 30 days of 
code A4239 will be denied as not reasonable and necessary. 
 
The records show that the Plan paid for 3 units of A4239 for date of service May 12, 2023 under claim ending 
in 5857. The A4239 code in dispute was billed under claim number ending in 7087 and was billed for date of 
service May 12, 2023. This exceeds Medicare quantity allowances for payment on this code. Therefore, we 
decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on May 
12, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF services provided from October 3, 2022, to 
October 31, 2022. 
 
You asked the Plan to pay for the SNF services. You say that the dates of service in question are coverable. The 
Plan denied your request. The Plan says the enrollee's 100-day SNF benefit was exhausted.  
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 25, 2023, 
through March 20, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may have still needed skilled care, the Plan is not required to pay for more than 100 days 
of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the 
enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.  Therefore, we decided that the Plan does not have to pay for the SNF services provided from October 3, 2022, 
to October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network hearing aid visit 
provided on May 11, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network hearing aid visit. You say that your 
audiologist is in-network, and they were in the room when this visit happened. 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 40% 
coinsurance for hearing services. 
 
You have been asked to pay 40% coinsurance for an out-of-network hearing aid visit. This item/service falls 
within the hearing services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The total you owe is $65.68. Therefore, we decided that the Plan does not have to waive 
the coinsurance for an out-of-network hearing aid visit provided on May 11, 2023.