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

 
We decided that the Plan does not have to pay for an office visit provided on June 08, 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 08, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ground mileage (A0425) and ambulance service, basic life 
support, non-emergency transport (A0428) provided on May 10, 2023. 
 
You asked the Plan to pay for ground mileage (A0425) and ambulance service, basic life support, non-
emergency transport (A0428). You say that due to the enrollee's weakness, dementia, and other health ailments, 
an ambulance is the safest way to transport her. The Plan denied your request. The Plan says this is not 
covered. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ground mileage (A0425) and ambulance service, basic life support, non-emergency transport 
(A0428) have not been met. Therefore, we decided that the Plan does not have to pay for ground mileage 
(A0425) and ambulance service, basic life support, non-emergency transport (A0428) provided on May 10, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted ambulance service (A0999) from one state to 
another provided on May 21, 2023. 
 
You asked the Plan to pay for an unlisted ambulance service (A0999) from one state to another. You say that 
you were both physically and mentally unable to be transported by airplane as you had very limited mobility 
with your legs, and recovering from a broken hip and a stroke. The Plan denied your request. The Plan says 
non-urgent ground transportation from one institution to another is covered only in cased of medical necessity. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an unlisted ambulance service from one state to another have not been met. Therefore, we decided 
that the Plan does not have to pay for an unlisted ambulance service (A0999) from one state to another 
provided on May 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (99284) provided on 
December 16, 2022. 
 
You asked the Plan to pay for the ER visit. 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 the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an emergency room (ER) visit (99284) 
provided on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic comprehensive preventive medicine reevaluation 
and management and screening for depression provided on January 12, 2023. 
 
You asked the Plan to pay for periodic comprehensive preventive medicine reevaluation and management and 
screening for depression. You say that the services 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 periodic comprehensive 
preventive medicine reevaluation and management and screening for depression provided on January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical procedure for isolation of tooth (D3910) provided 
on June 19, 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 surgical 
procedure for isolation of tooth (D3910) provided on June 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network genetic testing provided on 
May 17, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network genetic testing. You say that you were told by 
both the provider and plan, that this testing would be 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 20% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for an in-network genetic testing. This item/service falls within 
the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total you owe is $762.20 ($3811.03 allowed 
amount x 20% = $762.20). Therefore, we decided that the Plan does not have to waive the coinsurance for an 
in-network genetic testing provided on May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 7, 
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 limited oral evaluation (D0140) provided on August 7, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayments for the specialist office visit and x-rays provided on June 
16, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visit and x-rays. You say that the provide 
was practicing bad medicine, and you should not have to pay for these services. The Plan denied your request. 
The Plan says that the cost sharing was applied correctly. 
 
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. The Plan did not provide a copy of the correct Evidence of Coverage (EOC). 
Without the proper EOC, we are unable to confirm if cost sharing was applied correctly. Therefore, we decided 
that the Plan has to waive the copayments for the specialist office visit and x-rays provided on June 16, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, and psychotherapy services provided on 
April 12, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit, and psychotherapy services. You say that authorization is not 
required. 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 office visit, and psychotherapy services 
provided on April 12, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on May 03, 2023. 
 
You asked the Plan to pay for the pathology services. You say that the specimen was sent to your laboratory by 
a provider. 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 pathology services 
provided on May 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment management services provided on December 
31, 2022. 
 
You asked the Plan to pay for the treatment management services. You say that the provider must see all 
patients in the office that need care. 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 treatment 
management services provided on December 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on June 30, 2023. 
 
You asked the Plan to pay for the office visit provided by a chiropractor. You say that you should not have to 
pay for this visit because you were never told the initial visit would not be covered. The Plan denied your 
request. The Plan says this is not a covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on June 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the growth removal surgery provided on 
May 22, 2023. 
 
You asked the Plan to waive the copayment for the growth removal surgery. You say that you are on a limited 
income, and do not feel this copayment is a fair 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 $374 
copayment for outpatient surgery.  
You have been asked to pay a $374 copayment for the growth removal surgery. This item/service falls within 
the outpatient surgery 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 growth 
removal surgery provided on May 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance transportations provided on 
January 4, 2023, and January 5, 2023. 
 
You asked the Plan to waive the copayments for the ambulance transportations. You say that the enrollee 
cannot afford the copayments. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $245 copay for each Medicare-covered trip.  
 
 
 The enrollee has been asked to pay a $245 copayment for each ambulance transportation provided on January 
4, 2023, and January 5, 2023. The total amount the enrollee owes is $490 ($245 copayment x 2 transportations 
= $490). These items/services fall within the ambulance services benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayments for the ambulance transportations provided on January 4, 2023, and January 5, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction and consultation (D9310, D7210) provided on 
April 12, 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 an 
extraction and consultation (D9310, D7210) provided on April 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an angiogram and the injection services provided on March 
29, 2023. 
 
You asked the Plan to pay for an angiogram and the injection services. 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 angiogram and the 
injection services provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening of an enrollee, topical application of fluoride 
varnish, application of caries arresting medicament, caries preventive medicament application (D0190, D1206, 
D1110, D9410, D1354, D1355) provided on June 28, 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 screening of an enrollee, topical application of fluoride varnish, application of caries arresting 
medicament, caries preventive medicament application (D0190, D1206, D1110, D9410, D1354, D1355) 
provided on June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a four-month LifeVest rental (K0606) to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a four-month LifeVest rental. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested item can be provided by a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a four-month LifeVest rental (K0606) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 05, 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 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each office visit provided on April 03, 
2023, to July 20, 2023. 
 
You asked the Plan to reduce the copayment for each office visit. You say that you thought that you only had a 
$10 specialist 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 $40 
copayment for outpatient mental health care. 
 
You have been asked to pay a $40 copayment for each office visit. This item/service falls within the outpatient 
mental health 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. The total amount you owe is $120 ($40 copayment x 3 visits = $120). Therefore, we decided that 
the Plan does not have to reduce the copayment for each office visit provided on April 03, 2023, to July 20, 
2023.