Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a defibrillator provided on February 19, 
2023. 
 
You asked the Plan to reduce the coinsurance for a defibrillator. You say that you disagree with the 
coinsurance. 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 durable medical equipment and related supplies.  
You have been asked to pay 20% coinsurance for a defibrillator. This item/service falls within the durable 
medical equipment and related 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 amount you owe is $540.99 ($2,163.95 allowed amount x 20% = 
$540.99). Therefore, we decided that the Plan does not have to reduce the coinsurance for a defibrillator 
provided on February 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140) provided on 
December 27, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says your benefit for the requested item or 
service 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 service was exhausted on date of service December 27, 2022. 
Therefore, we decided that the Plan does not have to pay more for a limited oral evaluation (D0140) provided 
on December 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 additional home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
has cardiac disease and a left ventricular assist device (LVAD). He has been receiving home health services 
since May of 2023. There is no indication he has a feeding tube, parenteral medications, or complex wound 
care issues. He has been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The continued home health skilled nursing services are not medically necessary based on the 
submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 18 additional home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit for an excision provided on May 15, 2023. 
 
You asked the Plan to pay for an office visit for an excision. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit for an 
excision provided on May 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cystourethroscopy provided on May 
01, 2023. 
 
You asked the Plan to reduce the copayment for the cystourethroscopy. You say that you did not have surgery. 
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 $100 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. 
 
You have been asked to pay a $100 copayment for the cystourethroscopy. 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 copayment for the cystourethroscopy provided on May 01, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services an outpatient diagnostic 
test and rehabilitation services provided on May 31, 2023. 
 
You asked the Plan to waive the copayment for laboratory services an outpatient diagnostic test and 
rehabilitation services. 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 $10 copayment outpatient diagnostic test/lab services, a $140 copayment for outpatient diagnostic test/ /covered 
diagnostic procedure or test at a network outpatient facility and a $40 copayment for outpatient rehabilitation 
services.  
 
You have been asked to pay a $10 copayment for laboratory services, a $140 copayment for outpatient 
diagnostic test and a $40 copayment for rehabilitation services. The total amount you are being asked to pay 
$190 ($10 + $140 + $40 =$190). This item/service falls within the outpatient diagnostic test/lab 
services/covered diagnostic procedure or test at a network outpatient facility and 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. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services an 
outpatient diagnostic test and rehabilitation services provided on May 31, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes U0005 and U0003 provided on January 3, 2022. 
 
You asked the Plan to pay for procedure codes U0005 and U0003. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are included 
in the payment to the facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the record shows that the billing laboratory in this case performed 
the test. This means that they can be paid for these services. There is no documentation in the record to show 
that the SNF in this case has already billed or been paid for these specific services and intends to make 
payment under arrangements. The claim information for the SNF services includes only revenue codes and no 
procedure codes, so we cannot verify whether the services in question have already been requested/paid to the 
SNF facility. Therefore, we decided that the Plan has to pay for procedure codes U0005 and U0003 provided 
on January 3, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TENS device provided on April 22, 2023, by an OON 
provider.  
 You asked the Plan to pay for the TENS device. You say that you believe this claim was denied for the 
procedure code and diagnosis codes. The Plan denied your request. The Plan says the services were 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 TENS device provided on April 22, 2023, by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for durable medical equipment (DME) provided 
on March 2, 2023, to May 5, 2023. 
 
You asked the Plan to waive the cost share for DME. You say that you disagree with the cost hare. 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 $525 deductible which applies to durable medical equipment (DME).  
 
The item or service you asked the Plan to waive the cost share for falls within the durable medical equipment 
(DME) benefit category. The total amount you are being asked to pay is your $525 deductible. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $525 deductible which applies to 
durable medical equipment (DME). This cost sharing is a contractual obligation that had not been met at the 
time DME was received on March 2, 2023, to May 5, 2023. Therefore, we decided that the Plan does not have 
to waive the cost share for durable medical equipment (DME) provided on March 2, 2023, to May 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on May 29, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory service 
provided on May 29, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that TMS is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have received mental health 
therapy services and have been on antidepressant medication. You have a diagnosis of major depressive 
disorder; however, there is no documentation of improvement by 50 percent using prior TMS treatment, as 
required by the Medicare criteria. The services are therefore not reasonable or medically necessary at this time. 
 
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 pre-approve transcranial magnetic stimulation (TMS) therapy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear medicine heart study provided 
on June 16, 2023. 
 
You asked the Plan to waive the copayment for the nuclear medicine heart study. You say that this is a routine 
service, and feel you should not owe this 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 $160 
copayment for in-network outpatient diagnostic tests and therapeutic services. 
 
You have been asked to pay a $160 copayment for the nuclear medicine heart study. This item/service falls 
within the in-network 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 copayment for the nuclear medicine heart study provided on June 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 12, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. 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 office visit provided on June 12, 2023, by an 
OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-emergent ambulance transportation to a 
physician's office. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is bedbound and not able to sit in a 
wheelchair. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.   
The services you have asked the Plan to pre-approve are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pre-approve a non-emergent ambulance transportation to a 
physician's office.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 23, 
2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing 
facility care provided on May 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 05, 2023, to 
January 16, 2023. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
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 home health services 
provided on January 05, 2023, to January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement provided on April 28, 2023. 
 
You asked the Plan to pay for the debridement. You say that you are appealing the denial with supporting 
documentation. 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 debridement 
provided on April 28, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on May 18, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that if you receive services from a non-plan doctor, hospital, or other health care provider without 
getting approval from our plan, the Plan will not cover the service. 
 
  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 nursing facility care provided on May 18, 
2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair lift / stairway elevator.  
 
You asked the Plan to pay for a stair lift. You say that you would like reconsideration because the requested 
stair lift / stairway elevator is medically necessary. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair lift / stairway elevator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for skin cancer removal, and repair of wounds 
provided on June 12, 2023. 
 
You asked the Plan to reduce the copayment for skin cancer removal, and repair of wounds. You say that you 
believe that you have been incorrectly charged. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for surgery services provided at an outpatient hospital. 
 
You have been asked to pay a $300 copayment for skin cancer removal, and repair of wounds. This 
item/service falls within the surgery services provided at an outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce the copayment for skin cancer removal, and repair of wounds provided on June 12, 
2023.