Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on October 30, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance. 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 provided on 
October 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on March 19, 2022. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you are requesting reconsideration for the 
services provided. 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 inpatient hospital stay 
provided on March 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73140 billed for date of service March 30, 
2023. 
 You asked the Plan to pay for procedure code 73140. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 73140 is bundled into payment for code 73130. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 73140 
is a column II code to column I code 73130. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 73140 billed for date of service March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the office visit provided on February 9, 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 this 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 February 9, 2023, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 6, 
2023, by an OON provider.  
 
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 this 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 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 subsequent nursing facility care provided on 
March 6, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on March 
28, 2023. 
 
You asked the Plan to waive the coinsurance for a denosumab injection. You say that you have not had to pay 
for this service in the past. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a denosumab injection. This item/service falls within the 
Medicare Part B prescription drugs 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 $276.80 ($1,384.02 allowed amount x 20% = $276.80). 
Therefore, we decided that the Plan does not have to waive the coinsurance for a denosumab injection provided 
on March 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on February 22, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
February 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance ride provided on November 20, 2022. 
 
You asked the Plan to pay for an ambulance ride. You say that this was medically necessary and should be 
covered. This patient could not move on their own. 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 ambulance ride 
provided on November 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nebulizer with compressor provided on January 22, 2023. 
 
You asked the Plan to pay for a nebulizer with compressor. 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 a nebulizer with 
compressor provided on January 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the trigger point injection provided on 
March 14, 2023. 
 
You asked the Plan to reduce the copayment for the trigger point injection. 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 $280 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $280 copayment for the trigger point injection. This item/service falls within the 
outpatient surgery, including 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. However, since the allowed amount is 
less than the standard copayment, you only owe $256.83. Therefore, we decided that the Plan does not have to 
reduce the copayment for the trigger point injection provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) provided on May 30, 2023. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images . You say that your dentist 
required to take some x-rays since you had a compound on your teeth. You also say that the compound was 
done one year ago and needed to see what was going on underneath. The Plan denied your request. The Plan 
says your benefit for the intraoral - complete series of radiographic images  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 intraoral - complete series of radiographic images  was exhausted on date of service 
June 7, 2021. Therefore, we decided that the Plan does not have to pay for an intraoral - complete series of 
radiographic images (D0210) provided on May 30, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) services provided on December 27, 
2021. 
 
You asked the Plan to pay for the therapy services. You say that multiple claims were denied without a specific 
reason. The Plan denied your request. The Plan says the claim was not filed within the required timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the therapy services was not filed until February 2, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physical therapy (PT) services provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve frames (V2020), progressive lens (V2781) and a 
photochromatic tint (V2744) provided from January 3, 2023, to March 1, 2023. 
 
You asked the Plan to pre-approve frames (V2020), progressive lens (V2781) and a photochromatic tint 
(V2744). You say that you are sending documents again since the Plan had not received them. The Plan denied 
your request. The Plan says the provider was non-contract, there was no pre-authorization, no primary care 
provider (PCP) referral, and evidence of several contract providers in the area. 
 
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 they have pre-authorization. 
 
We looked at the file and the Plan's rules. The Plan rules say that authorization rules apply for out-of-network 
covered services. The record shows that the provider you saw was out-of-network and there is no evidence that 
prior authorization was obtained. Based on this information, we decided that the Plan's rules for coverage of 
frames (V2020), progressive lens (V2781) and a photochromatic tint (V2744) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve frames (V2020), progressive lens (V2781) and a 
photochromatic tint (V2744) provided from January 3, 2023, to March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on October 7, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that the ultrasound was medically necessary. The Plan 
denied your request. The Plan says that coverage of chiropractic service is specifically limited to treatment by 
means of manual manipulation. No other diagnostic or therapeutic service furnished by a chiropractor or under 
the chiropractors order is covered. 
 
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 an ultrasound provided on October 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the post and core in addition to crown (D2952), pontics 
(D6245 x 3) and retainer crown (D6740) provided on September 22, 2022. 
 
You asked the Plan to pay more for the dental services. You say that these procedures were unforeseen and 
necessary. 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 September 22, 2022. 
Additionally, the cost sharing was processed correctly. Therefore, we decided that the Plan does not have to 
pay more for the post and core in addition to crown (D2952), pontics (D6245 x 3) and retainer crown (D6740) 
provided on September 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Computed tomography (CT) provided on January 10, 2023. 
 
You asked the Plan to pay for Computed tomography (CT). 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 Computed tomography 
(CT) provided on January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
and bitewings - four radiographic images (D0274) provided on April 26, 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 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 intraoral - complete series of radiographic images was exhausted on date of service May 19, 2022. The bitewings are a covered benefit, but you have already reached your $2,000 annual 
maximum any remaining charges are your responsibility Therefore, we decided that the Plan does not have to 
pay for intraoral - complete series of radiographic images (D0210) and bitewings - four radiographic images 
(D0274) provided on April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on September 26, 2022, to 
December 19, 2022. 
 
You asked the Plan to pay for diabetic supplies. 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 diabetic supplies 
provided on September 26, 2022, to December 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit, and the aflibercept 
injection provided on February 22, 2023. 
 
You asked the Plan to waive the cost sharing for the office visit, and the injection. You say that the enrollee 
does not agree with the cost sharing. 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 20% coinsurance for Medicare Part B prescription drugs, and a $25 copayment per visit to an 
ophthalmologist or optometrist for Medicare-covered vision care. 
 
The enrollee has been asked to pay a $359.33 coinsurance for the injection ($1796.66 allowed amount x .20 = 
$359.33). This item/service falls within the Medicare Part B prescription drugs benefit category. The enrollee 
has also been asked to pay a $20 copayment for the office visit because the Plan is only holding them 
responsible for this amount which is less than the $25 copayment. This item/service falls within the vision care 
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 cost sharing for the office visit, and the 
aflibercept injection provided on February 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 heavy duty power operated vehicle (POV) 
(K0801). 
 
You asked the Plan to pre-approve a group 1 heavy duty POV. You say that you meet all of the criteria for 
coverage of a scooter. The Plan denied your request. The Plan says there is documentation that you are able to 
use a cane and walker inside the home but cannot leave your home with the assistive devices. The Plan also 
says that this POV is not reasonable or necessary at this time. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The records show that the requested POV is for use outside of the home. Although this item may be helpful, 
neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan 
does not have to pre-approve a group 1 heavy duty power operated vehicle (POV) (K0801).