Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on December 13, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you were told you would receive a check in the 
mail after ten days. You say you at least want to know what you receive after your copayment. The Plan denied 
your request. The Plan says the provider was out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only received by a network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided on December 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable x-ray provided on April 06, 2023. 
 
You asked the Plan to pay for a portable x-ray. You say that you are requesting reconsideration stating PPX is a 
Medicare certified provider in several states, including this state where the services were rendered. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a portable x-ray 
provided on April 06, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on May 23, 
2023. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you should not have to pay 
for 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 $30 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $30 copayment for an electrocardiogram. 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. However, since the allowed amount is less than the 
standard copayment, you only owe $14.27. Therefore, we decided that the Plan does not have to waive the 
copayment for an electrocardiogram provided on May 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on April 10, 2023. 
 
You asked the Plan to pay for ambulance services and ground mileage. You say that the submitted 
documentation supports the medical necessity for the non-emergent ambulance services. The Plan denied your 
request. The Plan says  the details we received do not meet the Medicare guidelines that show a medical reason 
for the round trip non-emergency ambulance transportation and ground mileage. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services and ground mileage. Our 
reviewer says that the ambulance services were not medically necessary.  
 Our physician reviewer found the documentation does not indicate bed confinement where the enrollee can't be 
moved by wheelchair and must be moved by stretcher. The enrollee did not require the expertise/equipment of 
an ambulance. The documentation also does not support that the ambulance transportation was medically 
reasonable or necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance services and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Shingrix vaccine and administration provided on June 8, 
2023. 
 
You asked the Plan to pay for a Shingrix vaccine and administration. You say that your insurance should have 
covered your vaccine. The Plan denied your request. The Plan says the requested vaccine is not covered under 
Part B benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Shingrix vaccine 
and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to a Shingrix vaccine 
and administration. Therefore, we decided that the Plan does not have to pay for a Shingrix vaccine and 
administration provided on June 8, 2023.  
 
Benefits for a Shingrix vaccine and administration may be available under Medicare Part D. Contact the Plan 
that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 29, 2022. 
 
You asked the Plan to pay for the laboratory 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 the laboratory services 
provided on December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each outpatient clinic visit provided on 
January 19, 2023, to June 08, 2023. 
 
You asked the Plan to reduce the copayment for each outpatient clinic visit. You say that you were changed 
incorrectly. 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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for each outpatient clinic visit. 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. However, since the allowed amount is less than the 
standard copayment, you only owe $43.49 for each visit. The total amount you owe is $86.98 ($43.49 
copayment x 2 visits = $86.98). Therefore, we decided that the Plan does not have to reduce the copayment for 
each outpatient clinic visit provided on January 19, 2023, to June 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image 
(D0230), bitewing - single radiographic image (D0270), and palliative treatment of dental pain  per visit 
(D9110) provided May 1, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the plan provided the name and address of 
a dental provider who you could go to for emergency out-of-area services. You also say that the provider 
verified they also accepted your insurance before making the appointment. The Plan denied your request. The 
Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider.   
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 limited oral evaluation - problem focused 
(D0140), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional 
radiographic image (D0230), bitewing - single radiographic image (D0270), and palliative treatment of dental 
pain  per visit (D9110) provided May 1, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 4, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for medical services. You say that this was medically necessary. The Plan denied 
your request. The Plan says services provided by an OON provider are 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 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 medical services provided on May 4, 2023, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on June 1, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this was the only provider who was able to see 
you right away. 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 dental services provided by an OON provider on June 1, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the records do show that it was expected at the time of admission that the enrollee's 
necessary hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 25210-59 rendered on April 11, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 25210 is considered inclusive to CPT 25447, and the documentation received does not 
support that CPT 25210 was distinct or independent from other services performed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
procedure details cite subperiosteal dissection was performed to expose and completely excise the trapezium. 
The arthroplasty space was then examined. There was an excision of the trapezium to visualize/prepare the 
arthroplasty space. Therefore, the documentation does not support CPT 25210: carpectomy, 1 bone as a separate and distinct procedure from CPT 25447: arthroplasty, interposition, intercarpal or carpometacarpal 
joints. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 25210-59 rendered on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810 x 3, 97811 x 3) provided 
from March 14, 2023, to May 2, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says acupuncture is only covered to treat CLBP. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services at issue were not used to treat CLBP.  
Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810 x 3, 97811 x 3) 
provided from March 14, 2023, to May 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics (L3000) provided on May 3, 2023.  
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit for your 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that inserts and other shoe modifications are covered 
if they are on a shoe that is an integral part of a covered brace, and if they are medically necessary for the 
proper functioning of the brace.    
 
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 items.   
 
 
 
Our reviewer says that you do not meet criteria for coverage of the orthotics provided in this case. Our 
physician reviewer found that the medical documentation provided supports that you presented to your 
podiatrist with painful corns, calluses, and painful first Metatarsophalangeal joints. You were casted for custom 
orthotics. In order for orthotics to be covered, the shoe insert must be an integral part of a covered brace, and 
medically necessary for the proper functioning of the brace. Per review of the medical information, it does not 
appear that the foot orthotics dispensed to you are an integral part of a covered brace. Furthermore, the foot 
orthotics dispensed do not appear to be medically necessary for the proper functioning of a brace. 
 
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 items have not been met. Therefore, we decided that the Plan does not 
have to pay for the foot orthotics (L3000) provided on May 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 6, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
The laboratory report with the billing provider's name was not submitted for verification of the provided 
services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 
6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on January 31, 2023, by an 
OON provider.  
 
You asked the Plan to pay for a home visit evaluation. 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 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 a home visit evaluation provided on January 31, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on July 6, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the podiatry services. You say that this is supported in the records. 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 podiatry services provided on July 6, 2023, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership (S9970) 
purchased on January 1, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not payable as your 
request for reimbursement was received untimely.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
 
 
 
The Plans rules for coverage of gym benefits have not been met because your request for reimbursement of 
this service was received untimely. Specifically, the Plans contract states that reimbursement requests for the 
Wellness allowance benefit must be received no later than March 31
st
 of the following year. The health club 
membership in this case was purchased for the 2022 calendar year and the record shows that your request for 
reimbursement of this service was received untimely on June 6, 2023. Therefore, we decided that the Plan does 
not have to issue reimbursement for the health club membership (S9970) purchased on January 1, 2022.