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

 
We decided that the Plan does not have to reduce the copayment for an in-network injection procedure 
provided on July 14, 2023. 
 
You asked the Plan to reduce the copayment for an in-network injection procedure. You say that this should 
only be a $35 specialist copayment, not a surgical 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 $350 
copayment for outpatient hospital services. 
 
You have been asked to pay a $350 copayment for an in-network injection procedure. 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 reduce the copayment for 
an in-network injection procedure provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each urgent care visit provided on June 04, 
2023, to August 30, 2023. 
 
You asked the Plan to waive the copayment for each urgent care visit. You say that you shouldnt have to pay 
because your doctors office was closed. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for urgently needed services. 
 
You have been asked to pay a $30 copayment for each urgent care visit. This item/service falls within the 
urgently needed 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 $120 ($30 copayment x 4 visits = $120). Therefore, we decided that 
the Plan does not have to waive the copayment for each urgent care visit provided on June 04, 2023, to August 
30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you require a LTACH admission due to 
the need of six weeks of antibiotics and your denial of a lower level of care. The Plan denied your request. The 
Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care setting.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous glucose monitor (CGM) and supplies (A4239) provided 
on July 20, 2023. 
 
You asked the Plan to pay for the CGM and supplies. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says that the documentation requirements have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order and proof of delivery. Review of the file does not reveal any 
reason that the required documentation is invalid. Therefore, we decided that the Plan has to pay for a 
continuous glucose monitor (CGM) and supplies (A4239) provided on July 20, 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 reimburse for an Apple watch (A9300) provided on July 15, 2023. 
 
You asked the Plan to reimburse for an Apple watch (A9300). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says your request for reimbursement and the proof of payment 
did not match your name as it appears in our records. The Plan also says therefore, we are unable to approve 
your request for reimbursement in the amount of $200 for the Apple Watch. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an apple watch (A9300) have been 
met. verification that you purchased the Apple watch. There is no verification that you bought one. Therefore, 
we decided that the Plan does not have to reimburse for an Apple watch (A9300) provided on July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 10, 2023. 
 
You asked the Plan to pay for practitioner services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the provider is not under contract with the Health 
Plan and is not Medicare eligible. 
 
The Plan must follow Medicare rules. Medicare rules say that certain individuals and entities frequently 
attempt to enroll in Medicare but are not eligible to do so. If the Medicare contractor receives an enrollment 
application from the individual or entity, the contractor shall deny the application. Naturopathic doctor (ND) is 
among the provider types that are not eligible to enroll in Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of practitioner services have not been met. Therefore, we decided that the Plan does not have to pay 
for practitioner services provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9501 billed for date of service January 28, 
2023, to February 2, 2023. 
 
You asked the Plan to pay for procedure code S9501. You say that the claim should be paid. 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 S9501 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9501 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9501 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9501 billed for date of service January 28, 2023, to February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper complete denture (D5110) and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 items was exhausted on date of service September 25, 2020. Specifically, 
the Plans contract states that one complete upper denture and one lower partial denture are covered every 60 
months.  
  
 
 
You previously received these dental items on September 25, 2020, less than 60 months prior, which were paid 
for by the Plan. Therefore, you have exhausted the allowable benefit for the requested dental items in this case. 
Therefore, we decided that the Plan does not have to pre-approve an upper complete denture (D5110) and a 
lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye examination (92014) provided on June 13, 
2023.  
You asked the Plan to pay for a routine eye examination (92014). You say that this same code for this same 
doctor was covered the previous year, so you see no reason it should not be covered this year. The Plan denied 
your request. The Plan says you must use a Plan Vision network provider. 
 
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 when you use a Plan Vision network provider for vision services. 
 
We looked at the file and the Plan's rules. The Plan rules say that you must use a Plan Vision network provider 
for routine eye examinations. The record shows the rendering provider was not a Plan Vision network provider. 
Based on this information, we decided that the Plan's rules for coverage of a routine eye examination (92014) 
have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye examination 
(92014) provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision supply or accessory (V2797) provided on June 30, 
2023.  
You asked the Plan to pay for vision supply or accessory (V2797). You say that before submitting this claim, 
you contacted the Plan's customer services and explained your situation to them. You also say you were 
assured by the Plan representative that based on the need to have new lenses; you would be appropriately 
reimbursed. The Plan denied your request. The Plan says the maximum 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 $240 combined allowance for eyeglasses and contact lenses every 24 months. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan pays up to $240 combined allowance 
for eyeglasses and contact lenses every 24 months. The record shows this benefit was exhausted on April 22, 
2022. Based on this information, we decided that the Plan's rules for coverage of vision supply or accessory 
(V2797) have not been met. Therefore, we decided that the Plan does not have to pay for vision supply or 
accessory (V2797) provided on June 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance services to be provided by an OON provider.  
 
You asked the Plan to pre-approve ambulance services. You say that the requested provider is only ambulance 
company who can transport the enrollee to their medical appointments in a timely manner. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider. 
 
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 
ambulance services to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network single-use endoscope used 
for a procedure provided on June 12, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network single-use endoscope used for a procedure. You 
say that this is a slap in the face. This extra charge feels like a mistake or theft. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for an in-network single-use endoscope used for a procedure. 
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. The total you 
owe is $664.46 ($3,652.42 x 20% = $664.46). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an in-network single-use endoscope used for a procedure provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visit on June 13, 2023. 
 
You asked the Plan to waive the cost share for the office visit. You say that you feel that you shouldn't have to 
pay any cost share for this 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 10% 
coinsurance of the approved amount. The annual deductible applies for provider services. There is a $232.61 
deductible and a $29.50 coinsurance. For the service it's $232.61 + $29.50 = $262.11. Therefore, results in the 
total cost sharing amount of $262.11. 
 
You have been asked to pay a $262.11 cost share for the office visit. This item/service falls within the doctor 
and other health care provider 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 cost share 
for the office visit on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic images (D0350 x 4) provided 
on June 26, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided are not covered under 
the supplemental dental policy.  
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial 
photographic images (D0350 x 4) provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on August 31, 2023. 
 
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 August 31, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on July 13, 2023. 
 
You asked the Plan to pay for procedure code 99285. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same 
day to the same patient by the same physician or more than one physician in the same specialty in the same 
group, only one service may be reported unless the services are for unrelated problems. Based on the 
documentation provided, this claim cannot be paid as billed due to the physician group relationship between the 
two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for procedure 
code 99285 provided on July 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the MRI and an injection on July 21, 2023, 
to August 25, 2023. 
 
 
 You asked the Plan to waive the copayments for the MRI and an injection. You say that you cannot afford to 
pay these bills. You cannot even afford to go to the doctors anymore. You are going through a financial 
hardship where your rent is more than your social security. 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 per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. You will 
only pay one copayment per day even if multiple diagnostic radiology services are performed. You most pay a 
$370 per day for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital. For both services it's, $325 
+ $370 = $695. Therefore, results in the total cost sharing amount of $695. 
 
You have been asked to pay a $325 copayment for the MRI and a $370 copayment for an injection. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies and outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for the MRI and an injection on July 21, 2023, to 
August 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on August 16, 2023. 
 
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 August 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on July 28, 2023. 
 
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 July 28, 2023.