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

 
We decided that the Plan does not have to pay for an office visit and x-rays provided on July 11, 2023. 
 
You asked the Plan to pay for an office visit and x-rays. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and x-rays 
provided on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) and panoramic 
radiographic image (D0330) provided on July 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or services 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 item or services was exhausted on date of service May 17, 2023. 
Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) and panoramic radiographic image (D0330) provided on July 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the oxygen equipment provided on July 10, 2023. 
 
You asked the Plan to reimburse for the oxygen equipment. You say that you purchased oxygen equipment 
from an out-of-network provider and would like to be reimbursed. The Plan denied your request. The Plan says 
you purchased the concentrator out right when it is supposed to be a rental item. Therefore, no payment will be 
made. 
 The Plan must follow Medicare rules. Medicare rules say that that Part A/Part B Medicare Administrative 
Contractors may not pay for oxygen equipment that is purchased on or after June 1, 1989. 
 
We looked at the file and Medicare rules. Specifically, the record shows you purchased the oxygen 
concentrator, and Medicare does not pay for purchased oxygen equipment. The Plan only pays for rented 
oxygen equipment. Based on this information, we decided that Medicare rules for coverage of the oxygen 
equipment have not been met. Therefore, we decided that the Plan does not have to reimburse for the oxygen 
equipment provided on July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the prosthetic eye provided on January 30, 2023. 
 
You asked the Plan to pay more for the prosthetic eye . You say that you are only liable for 20% of the $3,000 
cost. You say the plan incorrectly assessed the claim as out-of-network. The Plan denied your request. The Plan 
says the provider was out-of-network, however, the claim processed as in-network because the service was not 
available in-network. 
 
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 each in-network Medicare-covered service.   
You have been asked to pay $215.45 which is 20% of the allowed amount for the prosthetic eye. The allowed 
amount was $1,077.25. ($1,077.25 x 20% = $215.45). This service falls within the each in-network Medicare-
covered service benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to pay more for the prosthetic eye provided on January 
30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on September 08, 2023, to September 13, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you were not 
there for five days because you wanted to be. You thought you could leave after three. 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 inpatient hospital care.  
You have been asked to pay a $350 copayment for an in-network acute inpatient stay. This item/service falls 
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. You have been asked to pay a total of $1,750 for the inpatient hospital stay 
($350 copayment x 5 days = $1,750). You have not been charged for the day you were discharged. Therefore, 
we decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on September 08, 2023, to September 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on July 19, 2023. 
  
You asked the Plan to pay for the refraction. You say that there was a charge of $80 for the refraction. You say 
you paid $80 at the time of the visit. The Plan denied your request. The Plan says the refraction is not a covered 
benefit. 
 
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 provided during a routine eye examination. 
 
We looked at the file and the Plan's rules. Specifically, the eye refraction was provided during a medical eye 
examination. Based on this information, we decided that the Plan's rules for coverage of the refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on July 19, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 01, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the Plan does not have its 
own ambulance service, and you should not get charged for those 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 
$200.00 copayment for ambulance services..  
You have been asked to pay a $200.00 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on July 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for over-the-counter items provided on April 30, 2023. 
 
You asked the Plan to reimburse for over-the-counter items. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says your claim submission was received more than 120 days 
after the date of service. The Plan also says that submissions must be received within 120 days of the date of 
service or items purchase to be reimbursed. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter items is an OTC item. The record shows the reimbursement claim was received on September 5, 2023, 
which is more than 120 days from this date of service. Therefore, we decided that the Plan does not have to 
reimburse for over-the-counter items provided on April 30, 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 February 27, 
2023, through February 28, 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 was admitted to an inpatient status on February 27, 2023 for a diagnosis of 
ventricular tachycardia. The enrollee underwent an uncomplicated left heart catheterization, left 
ventriculogram, selective left and right coronary geography, and an instantaneous wave-free ratio (IFR) of a 
left anterior descending artery (LAD). The cardiac catheterization found mild nonobstructive epicardial 
coronary disease. He was started on 25 mg of Metoprolol daily and his statin dose was increased to 40 mg of 
atorvastatin daily. The enrollee was also instructed to discontinue use of Sudafed and Afrin which he had been 
using for his seasonal allergies. He was discharged with a heart monitor and advised to follow-up with 
Cardiology in 1 to 2 weeks. The review indicates 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 February 27, 2023, through February 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 12, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not want to go to the 
hospital. You would like reconsideration. 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 
$240.00 copayment for ambulance services. 
 
You have been asked to pay a $240.00 copayment for ambulance services. This item/service falls within the ambulance 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 ambulance services 
provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 29, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for over-the-counter items purchased on January 5, 2023. 
 
You asked the Plan to reimburse for over-the-counter items. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says your claim submission was received more than 120 days 
after the date of service. The Plan also says that submissions must be received within 120 days of the date of 
service or items purchase to be reimbursed. 
 
Medicare generally does not cover over-the-counter services. However, the Plan offers an over-the-counter 
benefit under the pick your perks reimbursement program that exceeds Medicare coverage. For that reason, the 
Plans coverage rules apply in this case.  
 
 
  The Plan rules say although that they do cover over-the-counter items in the pick your perks reimbursement 
program, you have 120 days from the purchase/date of service to submit your reimbursement claim and 
required documentation. The record shows the reimbursement claim was received on September 19, 2023, 
which is more than 120 days from the date services were received. Therefore, we decided that the Plan does not 
have to reimburse for over-the-counter items purchased on January 5, 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 May 19, 2023. 
 
You asked the Plan to waive the cost share for the office visit. You say that you never had to pay that much for 
an office visit, and you don't agree with the amount you should have to pay. 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 must 
pay a 10% coinsurance of the approved amount for diagnostic tests. The annual out-of-pocket maximum. There 
is a $281.68 deductible and a $36.58 coinsurance. For the service it's $281.68 + $36.58 = $318.26. Therefore, 
results in the total cost sharing amount of $318.26. 
 
You have been asked to pay a $318.26 cost share for the office visit. This item/service falls within the 
diagnostic tests benefits 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 
May 19, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy visits provided on July 
21, 2023, to July 31, 2023. 
 
You asked the Plan to waive the copayment for the physical therapy visits. You say that you were never told 
what your copayment was, so you should not have to pay the billed amount. 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 $65 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $65 copayment for the physical therapy visits. This item/service falls within the 
outpatient rehabilitation 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 $130 ($65 copayment x 2 visits = $130). Therefore, we 
decided that the Plan does not have to waive the copayment for the physical therapy visits provided on July 21, 
2023, to July 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on May 29, 2021, to June 04, 2021. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that this bill is old, 
you feel it should be forgiven and that you should not have to pay a copay for it. 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 $195 
copayment for inpatient hospital care.  
You have been asked to pay a $195 copayment for an in-network acute inpatient stay. This item/service falls 
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. You have been asked to pay a total of $1,365 for the inpatient hospital stay 
($195 copayment x 7 days = $1,365). You have not been charged for the day you were discharged. Therefore, 
we decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
on May 29, 2021, to June 04, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network cardiology visit provided on 
August 10, 2023. 
 
You asked the Plan to waive the copayment for an in-network cardiology visit. You say that you had canceled 
these appointments and should not have to pay a 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for an in-network cardiology 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 in-network cardiology visit provided on August 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay and x-
ray provided from July 6, 2023, to July 21, 2023. 
 
You asked the Plan to waive the copayment for an inpatient stay and x-ray. You say that you should not have to 
pay for each inpatient admission, back-to-back. It should count as one. 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 per day, for days one to five, for each inpatient hospital stay, and a $75 copayment for outpatient 
diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $1,825 copayment for an inpatient stay and x-ray ($350 copayment x 5 days = 
$1,750 + $75 = $1,825). This item/service falls within the inpatient hospital care and 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. Therefore, we decided that the Plan does not have to waive the copayment for 
an in-network acute inpatient stay and x-ray provided from July 6, 2023, to July 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on July 26, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were told that the prostate 
exam was covered with nocost share. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for the 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 the office visit provided on July 26, 2023.