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 April 12, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and 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 April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ankle fracture treatment provided on 
June 09, 2023. 
 
You asked the Plan to waive the copayment for the ankle fracture treatment. You say that you should pay for a 
postoperative follow-up 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 $45 
copayment for podiatry services. 
 
You have been asked to pay a $45 copayment for the ankle fracture treatment. This item/service falls within the 
podiatry 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 the ankle fracture 
treatment provided on June 09, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on May 20, 2022. 
 
You asked the Plan to pay for the laboratory service. 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 service 
provided on May 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic shoes and the shoe inserts provided on 
December 20, 2022. 
 
You asked the Plan to pay for the diabetic shoes and the shoe inserts. 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 diabetic shoes and 
the shoe inserts provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services outside the United States (U.S.). 
 
You asked the Plan to pay for the dental services. You say that you traveled out of the country and the dental 
services were performed due to an emergency. The Plan denied your request. The Plan says the dental services were received from a provider outside the United States, and were not medical services. The Plan also says that 
the services are not covered by your supplemental benefits.  
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover services outside of the 
United States. Medicare also 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 Plan only 
covers emergency services outside of the United States. 
 
We looked at the file, Medicare rules, and the Plan rules. The Plan rules say that they over coverage for 
emergency services outside of the U.S. The record shows you received the requested dental services from a 
provider outside of the U.S. 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 a provider outside of the 
U.S. The record does not show that these services were a medical emergency. Therefore, we agree with the 
Plan. Therefore, we decided that the Plan does not have to pay for dental services outside the United States 
(U.S.).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 14, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service was 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 an office visit provided 
on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring of physiologic parameter provided on 
October 31, 2022. 
 
You asked the Plan to pay for remote monitoring of physiologic parameter. You say that you say that you have 
attached medical records for review. 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 remote monitoring of 
physiologic parameter provided on October 31, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on May 
21, 2023, to May 22, 2023. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you say that you were 
not admitted and were only under observation and therefore, you should not owe the out of pocket cost for the 
date of service. 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 $110 
copayment for outpatient hospital services. 
 
You have been asked to pay a $110 copayment for emergency room services. This item/service falls within the 
outpatient hospital 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 emergency 
room services provided on May 21, 2023, to May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 23, 2023. 
 
You asked the Plan to pay for an office visit. You say that you say that the patient has been with you since 
2015 and you did not request prior authorization because the patients cared reads no referral required. 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 March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on August 10, 2022, to August 23, 
2022. 
 
You asked the Plan to pay for chiropractic care. You say that you feel that it should be approved because you 
called an asked if it was available with your insurance and was advised that it was. 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 chiropractic care 
provided on August 10, 2022, to August 23, 2022.
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 this is supported in the records. 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 2, 
2023. 
 
You asked the Plan to pay for the ED services. You say that you have provided medical records to show that 
the services rendered were medically necessary. The Plan denied your request. The Plan says Medicare 
payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 2, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
October 02, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you say that you visited 
the ER and was diagnosed with COVID-19 and feel like the plan should waive the $90 copay since you were 
diagnosed with COVID. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
emergency 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. Therefore, we decided that the Plan does not have to waive the copayment for emergency room services 
provided on October 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 14, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating you are 
submitting this formal appeal with medical records which shows that submitted services are 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 an office visit provided 
on June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercise provided by a chiropractor on May 
31, 2023. 
 
You asked the Plan to pay for the therapeutic exercise. You say that your insurance should cover the service 
you received. The Plan denied your request. The Plan says this is not a covered chiropractic service. 
 
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 records show that the service at issue is therapeutic exercise. Therefore, we decided that the Plan does not 
have to pay for the therapeutic exercise provided by a chiropractor on May 31, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 5, 
2023. 
 
You asked the Plan to pay for the ED services. You say that you are appealing the denied claim. The Plan 
denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 5, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an abdomen and pelvis computed 
tomography (CT) scan provided on May 11, 2023. 
 
You asked the Plan to reduce the copayment for an abdomen and pelvis computed tomography (CT) scan. 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 $300 
copayment for in-network advanced imaging services performed at an outpatient hospital. 
 
You have been asked to pay a $300 copayment for an abdomen and pelvis computed tomography (CT) scan. This item/service falls within the in-network advanced imaging services performed 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 reduce the copayment for an abdomen and pelvis 
computed tomography (CT) scan provided on May 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on January 11, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory service. 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 laboratory service provided on January 11, 
2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a urine test provided on June 14, 2023. 
 
You asked the Plan to waive the copayment for a urine test. You say that you did not receive any lab 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 a $5 
copayment for each Medicare-covered lab test. 
 
You have been asked to pay a $5 copayment for a urine test. This item/service falls within the each Medicare-
covered lab test 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 urine test provided on 
June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercise provided by a chiropractor on June 
14, 2023. 
 
You asked the Plan to pay for the therapeutic exercise. You say that the service you received should be covered 
by your insurance. The Plan denied your request. The Plan says this is not a covered chiropractic service. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the therapeutic exercise provided by a chiropractor on June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a complete upper denture (D5110) provided on July 25, 
2023. 
 
You asked the Plan to pay more for the dental service. You say that you did not use all your dental benefits for 
the year. The Plan denied your request. The Plan says your annual dental maximum benefit for the year 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 the Plan paid $119.48 for dental services on March 8, 2023. On March 15, 2023, the Plan paid $268.26 
for dental services. On July 11, 2023, the Plan paid $424.18 for dental services. On July 25, 2023, the Plan paid 
$188.08 for dental services. For the year of 2023 the Plan paid $1,000 ($119.48 paid + $268.26 paid + $424.18 
paid + $188.08 paid) for dental services; therefore, your annual dental maximum benefit for the year of 2023 
was exhausted on the date of service of July 25, 2023. Therefore, we decided that the Plan does not have to pay 
more for a complete upper denture (D5110) provided on July 25, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 1, 2023, to April 
30, 2023. 
 You asked the Plan to pay for home health services. You say that you are requesting the claim be reviewed and 
reprocessed for payment because the claim was rejected by Medicare. The Plan denied your request. The Plan 
says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for home health services provided from April 1, 2023, to April 
30, 2023.