Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
in-network provider from January 22, 2022, to February 4, 2022, and February 7, 2022, to February 17, 2022. 
 
You asked the Plan to waive the copayment for the two inpatient hospital stays. You say that you do not agree 
with having to pay 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 $320 
copayment per day, for days 1-5, for in-network inpatient hospital care. 
 
 You have been asked to pay a $3200 copayment for the two inpatient hospital stays ($320 x 10 days = $3200). 
These items/services fall within the 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 the inpatient hospital stay provided by an in-network provider from January 22, 
2022, to February 4, 2022, and February 7, 2022, to February 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on January 11, 2023.  
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you thought this was covered 
with your plan and want to know why the copay is so much. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for each outpatient hospital facility visit. The provider billed in the amount of $1,556 and the 
allowed amount is $221.11. This is less than the copayment amount. Therefore, results in the total cost sharing 
amount of $221.11. 
 
 You have been asked to pay a $221.11 copayment, which is less than the copayment for outpatient surgery. 
This item/service falls within the 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 copayment for 
outpatient surgery on January 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the colonoscopy provided on December 2, 
2022. 
 
You asked the Plan to reduce the cost share for the colonoscopy. You say that you had met your deductible on 
March 9, 2022. 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 $121 deductible which applies to outpatient surgery and other medical 
services provided at hospital outpatient facilities. Your contract with the Plan also says that there is 10% 
coinsurance for Medicare-covered surgery or other services. 
 
 
 You have been asked to pay $121, which satisfies your deductible for the colonoscopy. The remaining allowed 
amount after the deductible was satisfied is $158.05 ($279.05 original allowed amount - $121 deductible = 
$158.05). The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $121 
deductible which applies to outpatient surgery and other medical services provided at hospital outpatient 
facilities. This cost sharing is a contractual obligation that had not been met at the time the colonoscopy was 
received on December 2, 2022. 
 
You have also been asked to pay $15.81, which is 10% coinsurance of the remaining allowed amount for the 
colonoscopy ($158.05 remaining allowed amount x 10% = $15.81). You have been asked to pay a total of 
$136.81 ($121 deductible + $15.81 coinsurance = $136.81). This item/service falls within the outpatient 
surgery and other medical 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. Therefore, we decided that the Plan 
does not have to reduce the cost share for the colonoscopy provided on December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 receiver. 
 
You asked the Plan to pre-approve the Dexcom G6 receiver. You say that you are appealing the denied 
Dexcom G6 receiver because you need the supplies. The Plan denied your request. The Plan says only the 
preferred brand products listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a glucometer. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 receiver.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling (D2392, D2331) provided on January 25, 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.  
 
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. Therefore, we decided that the Plan does not have 
to pay for a filling (D2392, D2331) provided on January 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for myocardial perfusion imaging provided on 
February 2, 2023. 
 
You asked the Plan to reduce the cost share for myocardial perfusion imaging. You say that you are being 
charged more than 15%. 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 $110 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. Your contract with the Plan says that there is 15% coinsurance for each 
Medicare-covered diagnostic procedure and test. 
 
 You have been asked to pay $110, which satisfies the deductible. The remaining allowed amount is $1,247.53 
($1,357.53 allowed amount - $110 deductible = $1,247.53). The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $110 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
myocardial perfusion imaging was received on February 2, 2023 
 
You have also been asked to pay $187.13, which is 15% of the remaining allowed amount ($1,247.53 
remaining allowed amount x 15% = $187.13). You have been asked to pay a total of $297.13 ($110 deductible 
+ $187.13 coinsurance = $297.13). This item/service falls within the outpatient diagnostic tests and therapeutic 
services and supplies 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 cost share for myocardial perfusion 
imaging provided on February 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the urgent care visit, orthotic brace, and 
rehabilitation services provided on January 13, 2023. 
 
You asked the Plan to waive the cost share for the urgent care visit, orthotic brace, and rehabilitation services. 
You say that you should only have an urgent care visit 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 $35 
copayment for each out-of-network urgent care visit. Your contract with the Plan also clearly says that you 
must pay 40% coinsurance for out-of-network durable medical equipment and related supplies. Your contract 
with the Plan also clearly says that you must pay a $60 copayment for out-of-network outpatient rehabilitation 
services. 
 
You have been asked to pay a $35 copayment for the urgent care visit. This item/service falls within the 
urgently needed services benefit category. You have also been asked to pay $103.86, which is 40% coinsurance 
of the allowed amount for the orthotic brace ($259.65 allowed amount x 40% coinsurance = $103.86). This 
item/service falls within the durable medical equipment and related supplies benefit category. You have also 
been asked to pay $47.97, which is less than the standard $60 copayment for the rehabilitation services. This 
item/service falls within the outpatient rehabilitation services benefit category. 
 
You have been asked to pay a total of $186.83 ($35 copayment + $103.86 coinsurance + $47.97 copayment = 
$186.83). 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 urgent care visit, orthotic brace, and 
rehabilitation services provided on January 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right foot orthotic (L3020).  
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although an 
orthotic may be appropriate for you, neither Medicare nor the Plan provides coverage of an orthotic for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a right foot orthotic (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on January 11, 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 services denied correctly as they do not fall 
within your dental 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 scaling 
in presence of generalized moderate or severe gingival inflammation (D4346) provided on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery) (D6011 x 2), custom fabricated abutmentsincludes placement (D6057 x 2), and an abutment 
supported porcelain fused to metal crown (high noble metal) (D6059 x 2). 
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says the requested items/services 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 requested items/services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical access to an implant body (second stage implant surgery) (D6011 x 2), custom fabricated abutments
includes placement (D6057 x 2), and an abutment supported porcelain fused to metal crown (high noble metal) 
(D6059 x 2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are currently stable for discharge and requesting 
daily skilled services provided at an IRF. The Plan denied your request. The Plan says the enrollee does not 
meet the requirements for an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a 
different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0152, G0299, Q5001) 
provided on March 31, 2022, to April 4, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 31, 2022. The NOA was not received by the Plan until May 9, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, G0152, 
G0299, Q5001) provided on March 31, 2022, to April 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical procedure of the ankle, and the removal of the 
plate provided on November 17, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the ankle procedure and the removal of the plate. You say that these services 
were medically necessary. 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 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 
items/services 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 surgical procedure of the ankle, and the 
removal of the plate provided on November 17, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on January 04, 
2023. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that the colonoscopy should be fully 
covered. 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 $295 
copayment for outpatient hospital services. 
 
You have been asked to pay a $295 copayment for the colonoscopy. 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. The medical records show this was a diagnostic colonoscopy. Therefore, we decided that 
the Plan does not have to waive the copayment for the colonoscopy provided on January 04, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
November 11, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you thought the Plan 
would fully cover 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 $85 
copayment for emergency care. 
 
You have been asked to pay a $85 copayment for the emergency room 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 the emergency room visit 
provided on November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 12, 2023, by an out-of-
network (OON) provider.  
 
 You asked the Plan to pay for an office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be covered. This means you will have to 
pay the provider in full for the services furnished. 
 
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 an office visit provided on January 12, 2023, by an 
out-of-network (OON) provider.