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

 
We decided that the Plan does not have to pay for the office visit and the skin biopsy provided on April 24, 
2023, by an OON provider.  
 
You asked the Plan to pay for the office visit and the skin biopsy. 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 and the skin biopsy provided on 
April 24, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for each catheter supply provided on June 14, 
2023, to July 13, 2023. 
 
You asked the Plan to reduce the coinsurance for each catheter supply. You say that the cost share is too high. 
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 prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for each catheter supply. This item/service falls within the 
prosthetic devices 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 for each supply is $349.20 ($1,746 allowed amount x 20% 
= $349.20). The total amount you owe is $698.40 ($349.20 coinsurance x 2 supplies = $698.40). Therefore, we 
decided that the Plan does not have to reduce the coinsurance for each catheter supply provided on June 14, 
2023, to July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision services provided on June 06, 2023. 
 
You asked the Plan to waive the copayment for vision services. You say that you were told that you would not 
be charged for the re-exam. 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 vision care. 
 
You have been asked to pay a $30 copayment for vision services. This item/service falls within the vision 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. Therefore, we decided that the Plan does not have to waive the copayment for vision services provided on June 
06, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a PET scan and the diagnostic agent 
provided on January 24, 2023. 
 
You asked the Plan to reduce the cost share for a PET scan and the diagnostic agent. You say that you were 
unaware of the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $85 
copayment for other Medicare-covered radiological diagnostic services. Your contract with the Plan also 
clearly says that you must pay 20% coinsurance for Medicare-covered Part B drugs other than allergy antigens. You have been asked to pay $85 copayment for a PET scan. 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.  
 
You have also been asked to pay $919.12, which is 20% coinsurance of the allowed amount for the diagnostic 
agent ($4,595.58 allowed amount x 20% = $919.12). This item/service falls within the Medicare Part B 
prescription drugs benefit category. The total amount you owe is $1,004.12 ($85 copayment + $919.12 
coinsurance = $1,004.12). 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 cost share for a PET scan and the 
diagnostic agent provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve flex card  rollover for over the counter services. 
 
You asked the Plan to pre-approve flex card  rollover for over the counter services. You say that you are 
requesting for the first, second, and third quarter over-the-counter benefit. You also say that because you did 
not know about the benefit and also the phone number to request the flex card until October. The Plan denied 
your request. The Plan says funds are provided on a debit card that will be funded every quarter. The Plan also 
says unused amounts in each quarter do not roll over to the next quarter. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and flex card - 
rollover is an OTC item. Therefore, we decided that the Plan does not have to pre-approve flex card  rollover 
for over the counter services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that she needs this otherwise she will fall in the 
shower. You also say that she has two bad legs, can barely walk and it is hard for her to take showers and needs 
this item to sit on to help bathe. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 pre-approve a shower chair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional transportation. The 
Plan denied your request. The Plan says the records show you have used 46 of your allowed 48 trips. 
Additional trips beyond 48 is not covered. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional trips. Based on this information, we decided that you have exhausted the Plan maximum benefit for 
coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided on June 28, 
2023. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you say that the plan should 
not be responsible. 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 urgently needed services. 
 
You have been asked to pay a $40 copayment for urgent care services. This item/service falls within the 
urgently needed 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 urgent care 
services provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 23, 2023. 
 
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 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 office visit provided 
on June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 items was exhausted on date of service May 27, 2020.   
 
 
 
 
Specifically, the Plans contract states that complete dentures are covered once every 60 months, per arch. You 
previously received complete dentures on March 27, 2020, less than 60 months prior, which were paid for by 
the Plan. Therefore, you have exhausted the allowable benefit for these items. Therefore, we decided that the 
Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 7, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the claim was late due to lack on enrollee's 
insurance information. The Plan denied your request. The Plan says the claim was not filed within the time 
limit. 
 
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 ambulance services was not filed until May 24, 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 the ambulance services provided on April 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from July 20, 2023, to July 
21, 2023. 
 
You asked the Plan to pay for the medication. You say that you feel the medication received while at the 
hospital facility should be covered by the Plan. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from July 20, 2023, to July 21, 2023.  
 
Benefits for the medication 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and endodontic 
therapy, of a molar tooth (excluding restoration) (D3330).  
 
You asked the Plan to pre-approve this item/service. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested item/service are not covered under the 
supplemental dental policy.  
 
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 item and service are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
porcelain/ceramic crown (D2740) and endodontic therapy, of a molar tooth (excluding restoration) (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an alveoloplasty (D7311) provided on August 21, 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 
alveoloplasty (D7311) provided on August 21, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on May 17, 
2023, to June 23, 2023. 
 
You asked the Plan to pay for the outpatient mental health 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 outpatient mental 
health services provided on May 17, 2023, to June 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for photochemotherapy services provided on 
July 07, 2023. 
 
You asked the Plan to reduce the copayment for photochemotherapy services. You say that the provider should 
be in-network. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 
copayment for out-of-network services from a specialist or under certain circumstances, treatment by a nurse 
practitioner, physicians assistant or other non-physician health care professional in a specialists office.  
You have been asked to pay a $65 copayment for photochemotherapy services. This item/service falls within 
the out-of-network services from a specialist or under certain circumstances, treatment by a nurse practitioner, 
physicians assistant or other non-physician health care professional in a specialists office 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 photochemotherapy services provided on July 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on July 28, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that you say that you have attached medical 
records for review. 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 visit for 
evaluation provided on July 28, 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 (bls), non-emergency transport, (A0428) provided on March 16, 2023. 
 
You asked the Plan to pay for ground mileage (A0425) and ambulance service, basic life support (bls), non-
emergency transport, (A0428). You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says this was denied because the details they received from the provider does not meet 
Medicare guidelines that show a medical reason the enrollee needs 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 ground mileage (A0425) and ambulance 
service, basic life support (bls), non-emergency transport, (A0428). Our reviewer says that the enrollee does 
not meet the criteria for ground mileage (A0425) and ambulance service, basic life support (bls), non-
emergency transport, (A0428). Our physician reviewer found other modes of transportation were not 
contraindicated. Our physician reviewer also found that the use of the ambulance was not medically reasonable 
or necessary. 
 
We looked at this physician's review, 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 (bls), 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 (bls), non-emergency transport, (A0428) 
provided on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments-includes placement for 
teeth number 30 and 31 (D6057 x 2) and abutment supported porcelain/ceramic crowns for teeth number 30 
and 31 (D6058 x 2).  
 
You asked the Plan to pre-approve the dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 items was previously exhausted. Specifically, the Plans contract states 
that up to two dental implants are covered per year. The Plan previously approved two dental implants for teeth 
number 3 and 4. Therefore, you have exhausted the allowable benefit for the dental items requested in this case 
at this time. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutments-
includes placement for teeth number 30 and 31 (D6057 x 2) and abutment supported porcelain/ceramic crowns 
for teeth number 30 and 31 (D6058 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on November 12, 2022. 
 
You asked the Plan to pay for the wound care supplies. 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 wound care supplies 
provided on November 12, 2022.