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

 
We decided that the Plan does not have to pay for the office visit provided on January 24, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. 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 24, 2023, by 
an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment, methadone (G2067) 
provided on June 5, 2023, by an OON provider.  
 
You asked the Plan to pay for the medication assisted treatment. You say that Medicare require payment for 
these services. The Plan denied your request. The Plan says the services are 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 medication assisted treatment, methadone 
(G2067) provided on June 5, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 8, 2023, to May 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel like the Plan should pay more of this. 
The Plan denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount was exhausted on date of service May 11, 2023. Therefore, we 
decided that the Plan does not have to pay for dental services provided on May 8, 2023, to May 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the laboratory services provided on May 
25, 2023. 
 
You asked the Plan to waive the cost sharing for the laboratory services. You say that this should have been 
considered part of your wellness exam. 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. Your 
contract with the Plan says that there is a $100 deductible which applies to outpatient diagnostic tests and 
therapeutic services. Your contract with the Plan also says that you must pay 10% coinsurance after meeting 
the deductible for outpatient diagnostic lab tests. 
 
 The medical records show the laboratory tests were diagnostic, and the cost sharing was correctly applied. You 
have been asked to pay $14.43 towards the deductible. The item or service you asked the Plan to waive the cost 
sharing for falls within the outpatient diagnostic tests and therapeutic services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $100 deductible which applies to 
outpatient diagnostic tests and therapeutic services. This cost sharing is a contractual obligation that had not 
been met at the time the laboratory services was received on May 25, 2023.  
 
You have also been asked to pay 10% coinsurance for the laboratory tests. This item/service falls within the 
outpatient diagnostic tests and therapeutic 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 sharing for the laboratory services provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral imaging 
(D0220) provided on June 19, 2023. 
 
You asked the Plan to pay for D0140 and D0220. You say that you had tooth pain and needed to have it looked 
at. The Plan denied your request. The Plan says the denied dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140), and intraoral imaging (D0220) provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided on July 10, 2023. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that you are requesting reconsideration for 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
stay provided on July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee replacement to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the knee replacement. You say that this enrollee has had this surgery in the 
past. The Plan denied your request. The Plan says enrollees 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 item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
total knee replacement to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hand x-ray provided on June 01, 2023. 
 
You asked the Plan to pay for a hand x-ray. You say that the plan didnt pay anything towards your bill, please 
re-access. 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 hand x-ray provided 
on June 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 25, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85025 and 80053 for date of service April 
20, 2023. 
 
You asked the Plan to pay for procedure codes 85025 and 80053. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 85025 and 80053 are not supported in the medical record. Specifically, the medical 
records submitted references a Clinical Laboratory Improvement Amendments of 1988 (CLIA), where as the 
claim form references a different CLIA. Due to this discrepancy, the services cannot be verified. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 85025 and 80053 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 85025 and 80053 for date of 
service April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on June 2, 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 June 2, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PNS. 
 
You asked the Plan to pre-approve PNS. You say that the enrollee requires the requested procedure to help with 
bilateral knee pain. The Plan denied your request. The Plan says the requested device is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 PNS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested procedure would be considered experimental/ investigational to treat the pain 
of osteoarthritis of the knee. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PNS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve PNS.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 14, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary and should be 
covered. Referral attached 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 laboratory services 
provided on July 14, 2023.
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 of payment 
stating why claim was not paid. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-rays, and 
cleaning (D0210, D1110, D0150) provided on June 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. Additionally, this benefit does not include 
intraoral x-rays 
 
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. 
 
 The record shows you received the requested dental services from an out-of-network provider. 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 an out-of-network provider. Additionally, this benefit does not include 
intraoral x-rays. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation, 
intraoral x-rays, and cleaning (D0210, D1110, D0150) provided on June 22, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
July 18, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you should not be 
responsible for the ER copayment because you were advised to go for no reason. 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 an emergency room (ER) visit. 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 an emergency room 
(ER) visit provided on July 18, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 1, 
2023, through August 2, 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 acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee underwent a planned left total knee arthroplasty. The enrollee was medically 
stable and had an uneventful postoperative course. The planned procedure listed under current procedural 
terminology (CPT) code 27447-80 is not listed on the Centers for Medicare and Medicaid Services (CMS) 
Inpatient Only List. The procedure was approved as an ambulatory procedure. There was no documentation 
provided to support the expectation that the enrollee would require a greater than two midnight stay. The 
review has determined that the record did not show that at the time of the inpatient admission it was reasonable 
for the admitting physician to expect that the enrollees necessary hospital care (including earlier emergency 
department (ED) and/or observation care) would span two midnights with supporting documentation of the 
enrollees history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from August 1, 2023, through August 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on November 10, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you say that the insurance paid the 
balance due. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on November 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services and inpatient hospital 
care provided on April 12, 2023, to May 9, 2023. 
 
You asked the Plan to waive the copayment for ambulance services and inpatient hospital care. You say that 
you disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for ambulance services and a $350 copayment per day for days 1-5 for inpatient hospital care.  
 You have been asked to pay a $275 copayment for ambulance services and a $350 copayment per day for days 
1-5 for inpatient hospital care. However, since the allowed amount is less than the standard copayment, you 
only owe $269.33 for the ambulance services. The total amount you owe for inpatient care is $1,750 ($350 x 5 
days = $1,750). The total amount you are being asked to pay is $2,019.33 ($1,750 + $269.33 = $2,019.33). This 
item/service falls within the ambulance services and Inpatient hospital care benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for ambulance services and inpatient hospital care provided on April 12, 
2023, to May 9, 2023.