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

 
We decided that the Plan does not have to reduce the copayment for each debridement procedure provided on 
May 31, 2023, to July 19, 2023. 
 
You asked the Plan to reduce the copayment for each debridement procedure. You say that you disagree with 
the copayments. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for in-network outpatient surgery including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $325 copayment for each debridement procedure. This item/service falls within 
the in-network outpatient surgery including services provided at hospital outpatient facilities benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total amount you owe 
is $2,275 ($325 copayment x 7 procedures = $2,275). Therefore, we decided that the Plan does not have to 
reduce the copayment for each debridement procedure provided on May 31, 2023, to July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a manual wheelchair provided on June 09, 2023. 
 
You asked the Plan to pay for a manual wheelchair. You say that you were under the impression that all of the 
authorizations were submitted and settled by the doctors. 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 manual wheelchair 
provided on June 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health care office visit provided on June 01, 2023. 
 
You asked the Plan to pay for the mental health care office visit. You say that you are requesting 
reconsideration for 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 mental health care 
office visit provided on June 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for extractions (D7210), and a diagnostic consultation 
(D9310) provided on May 16, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were told that this would be covered 
100%. 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. A $25 copayment was applied to D7210 for tooth #31 and #3. Therefore, we decided that the Plan does not have to 
pay more for extractions (D7210), and a diagnostic consultation (D9310) provided on May 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on May 04, 2023. 
 
You asked the Plan to pay for the pathology services. You say that the specimen was sent to your laboratory by 
a network provider. 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). The records show the referring provider was out-of-network on the date of service. 
Therefore, we decided that the Plan does not have to pay for the pathology services provided on May 04, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health visits provided on April 05, 2023, to May 
02, 2023. 
 
You asked the Plan to pay for the mental health visits. You say that you are requesting reconsideration of the 
denied claims. 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 mental health visits 
provided on April 05, 2023, to May 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown (D2740) provided on March 28, 
2023. 
 
You asked the Plan to waive the coinsurance for D2740. You say that you were not told that there would be a 
20% coinsurance. 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% 
coinsurance for dental services/out-of-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for D2740. The total allowed amount is 
$1,337. The total amount you are being asked to pay is $267.40 (D1,337 x 20% = $267.40). This item/service 
falls within the dental services/out-of-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a crown (D2740) provided on March 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 03, 2022. 
 
You asked the Plan to pay for lab services. You say that this is an independent laboratory. 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 lab services provided on 
November 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 07, 2023. 
 
You asked the Plan to pay for the office visit. You say that a referral is not needed for this service. 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 February 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on June 17, 2023. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that this patient is in a facility, and you 
depend upon the facility staff for any verification or prior authorization. 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 skilled nursing facility 
visit provided on June 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 30, 2023. 
 
You asked the Plan to pay for D0140. You say that you do not understand why a limited exam would not be 
covered. The Plan denied your request. The Plan says the denied dental service is not a covered benefit. 
 
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 limited 
oral evaluation (D0140) provided on May 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on March 04, 2023, to 
March 31, 2023. 
 
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 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 nursing facility care 
provided on March 04, 2023, to March 31, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each vedolizumab injection provided on 
February 03, 2023, to May 19, 2023. 
 
You asked the Plan to waive the coinsurance for each vedolizumab injection. You say that you cannot afford 
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 20% 
coinsurance for other in-network Medicare-covered Part B drugs. 
 
You have been asked to pay 20% coinsurance for each vedolizumab injection. This item/service falls within the 
other in-network Medicare-covered Part B 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. The total amount you owe is $5638.50 ($28,192.50 allowed 
amount x 20% = $5638.50). Therefore, we decided that the Plan does not have to waive the coinsurance for 
each vedolizumab injection provided on February 03, 2023, to May 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the enrollee has a collapsed 
and fluid on the right lung and has difficulty breathing. You also say he needs an easy way to carry oxygen 
equipment for his doctors appointments as the tanks are heavy and are difficult to push. The Plan denied your 
request. The Plan says our records show that you have an approval for a standard portable and concentrator. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for abdominal aortic aneurysm screening provided on  
July 17, 2023. 
 
You asked the Plan to pay for the abdominal aortic aneurysm screening. You say that you were unaware that 
this is a one-time benefit. The Plan denied your request. The Plan says you had received an abdominal aortic 
aneurysm screening on November 30, 2022, and have exhausted the benefit. 
 
The Plan contract says that abdominal aortic aneurysm screening is a one-time screening ultrasound for people 
at risk.   
 
We looked at the file and the Plans rules. The file shows that you have exhausted the benefit limit. Based on 
this information, we decided that Plans rules for coverage of the abdominal aortic aneurysm screening have 
not been met. Therefore, we decided that the Plan does not have to pay for abdominal aortic aneurysm 
screening provided on July 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an eye exam provided on November 1, 2022. 
 
You asked the Plan to reimburse you for the eye exam. You say that the claim was coded incorrectly and this 
eye exam was for a puckering of macula, left eye. The Plan denied your request. The Plan says the benefit has 
been exhausted. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
We looked at the file and the Plan's rules. The file shows that the eye exam benefit has been exhausted. 
Therefore, we decided that the Plan does not have to reimburse you for an eye exam provided on  
November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on July 07, 2023. 
 
You asked the Plan to pay for subsequent hospital 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 hospital care 
provided on July 07, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy services. 
 
You asked the Plan to pre-approve the psychotherapy services. You say that you were referred to this provider 
and you would like to continue working with her. The Plan denied your request. The Plan says Licensed 
Professional Counselors are on the list of individuals and entities that frequently attempt to enroll in Medicare 
but are not eligible to do so. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network outpatient hospital stay 
provided on April 13, 2023. 
 
You asked the Plan to waive the copayment for an in-network outpatient hospital stay. You say that you are 
being asked to pay so much for a treatment room. You do not understand all these different charges. 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 Outpatient hospital observation. 
 
You have been asked to pay a $245 copayment for an in-network outpatient hospital stay. 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 $ 130.53. Therefore, we decided that the Plan does not have to waive the copayment 
for an in-network outpatient hospital stay provided on April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 1, 2023, 
to June 17, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 1, 2023, to June 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a soft tissue head and neck ultrasound 
provided on June 19, 2023. 
 
You asked the Plan to waive the copayment for a soft tissue head and neck ultrasound. You say that you think 
that the copayment should be lower. 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 $75 
copayment for in-network diagnostic procedures and tests, including ultrasounds, at all locations of service. 
 
You have been asked to pay a $75 copayment for a soft tissue head and neck ultrasound. This item/service falls within the in-network diagnostic procedures and tests, including ultrasounds, at all locations of service 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 soft tissue head and neck ultrasound provided 
on June 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on May 18, 2023. 
 
You asked the Plan to pay for a duplex scan. You say that 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 a duplex scan provided 
on May 18, 2023.