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

 
We decided that the Plan does not have to pay for the extracapsular cataract removal provided on November 
30, 2022. 
 
You asked the Plan to pay for the extracapsular cataract removal. You say that you are appealing the denial 
with supporting documentation. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the extracapsular 
cataract removal provided on November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the new patient office visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that this provider is highly recommended. The Plan 
denied your request. The Plan says you must receive your 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 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 item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
new patient office visit 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 December 19, 2022. 
 
You asked the Plan to pay for an office visit. You say that you do not understand why you are being charged. 
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 December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a seat lift mechanism provided on June 12, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to reimburse for a seat lift mechanism. You say that you were unaware you had to go to a 
DME store to get lift chair.  The Plan denied your request. The Plan says the enrollee can receive their care 
from in-network and out-of-network providers, however the enrollee will typically pay less if they use an in-
network provider (for more information about this, see Section 2 in Chapter). When the enrollee receives care 
from an in-network provider the enrollee will be covered under their in-network benefit (HMO). When the 
enrollee receives care from an out-of-network provider the enrollee will be covered under their out-of-network 
benefit Point-of-Service (POS). 
 
 
 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 reimburse for a seat lift mechanism provided on June 12, 
2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 2, 
2023, through March 3, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.   
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee had an elective revision of a reverse right shoulder arthroplasty on March 2, 
2023. There were no surgical complications reported. He received 325 mg of Tylenol every 8 hours for pain 
control. Deep vein thrombosis (DVT) prophylaxis was 81 mg of aspirin. The next morning, the enrollee was 
feeling well with no pain. He ambulated in the hall without assistance and was discharged home. The planned 
procedure listed under current procedure terminology (CPT) code 23472 is not listed on the Centers For 
Medicare and Medicaid Services (CMS) Inpatient Only List. The procedure is currently approved as an 
ambulatory procedure. There was no documentation from the provider stating that the anticipated length of stay 
was expected to exceed a greater than two midnight stay. The review has determined that the record did not 
show that at the time of the inpatient admission it was reasonable for the admitting physician to expect that the 
enrollees necessary hospital care (including earlier emergency department (ED) and/or observation care) 
would span two midnights with supporting documentation of the enrollees history and comorbidities, signs 
and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from March 2, 2023, through March 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for progressive lenses (V2781), frames (V2025), and non-
discountable items and warranties (V2797) provided on May 4, 2023. 
 
You asked the Plan to reimburse for progressive lenses (V2781), frames (V2025), and non-discountable items 
and warranties (V2797). You say that you are appealing with supporting records. The Plan denied your request. 
The Plan says benefits available under this Plan cannot be combined with any other in-store discounts. 
 
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 you do not combine your benefit with in-store or provider 
discounts. 
 
We looked at the file and the Plan's rules. The Plan rules say that benefits available under this Plan cannot be 
combined with any other in-store discounts. The record shows that you use a provider promotion, which cannot 
be combined with your benefit. Based on this information, we decided that the Plan's rules for coverage of 
progressive lenses (V2781), frames (V2025), and non-discountable items and warranties (V2797) have not 
been met. Therefore, we decided that the Plan does not have to reimburse for progressive lenses (V2781), 
frames (V2025), and non-discountable items and warranties (V2797) provided on May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the panoramic radiographic image (D0330) 
provided on March 28, 2023. 
 
You asked the Plan to waive the copayment for the panoramic radiographic image. You say that you cannot 
afford your dental bills and the cost share for services is causing you a financial hardship. 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 a panoramic radiographic image and a 20% discount off the specialists customary fee when 
services are performed by a plan specialist. 
 You have been asked to pay a $40 copayment for the panoramic radiographic image. This service falls within 
the dental services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the panoramic 
radiographic image (D0330) provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
from June 14, 2021, to June 20, 2021. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you need this 
copayment amount waived because you cannot afford it. 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 $350 
copayment per day, for days 1 to 5 for inpatient hospital care.  
 
You were in the hospital for 5 days, resulting in a $1,750 total copayment (5 days x $350 = $1,750). You have been asked to pay a $1,750 total copayment for an in-network acute inpatient stay. This item/service 
falls within the inpatient hospital 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 
an in-network acute inpatient stay provided from June 14, 2021, to June 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
March 05, 2023. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you were told there 
would be no charge. 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 $350 
copayment for ambulance services. 
 
You have been asked to pay a $350 copayment for an ambulance transportation. 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 an 
ambulance transportation provided on March 05, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on May 
12, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that this was not a new 
diagnostic service, as your eye doctor has been monitoring your eyes for any changes due to diabetes or 
cataracts for some time now. The Plan denied your request. The Plan says this visit was not a routine eye exam. 
The Plan also says that the provider's office has confirmed that it was a medical visit, not a routine vision care 
visit. 
 
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 are a part of a routine examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that Original Medicare does not cover routine eye 
examinations (eye refractions) for eyeglasses/contacts. Based on this information, we decided that the Plan's 
rules for coverage of a determination of refractive state (92015) have not been met. Therefore, we decided that 
the Plan does not have to pay for a determination of refractive state (92015) provided on May 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on June 08, 2023. 
 
You asked the Plan to pay for a facility visit. You say that the enrollee is in a facility and the facility should 
have obtained the prior authorization. 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 facility visit provided 
on June 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids provided by an out-of-network provider. 
 
You asked the Plan to pre-approve hearing aids provided by an out-of-network provider. You say that the 
appliances the Plan sold you in 2011 have proven to be defective and have given you nothing but grief for the 
last two years. You also say that the reason you want to purchase the hearing aids through this provider is due 
to the lower cost and that you are not pleased with the previous hearing aids. The Plan denied your request. The 
Plan says the service sought or obtained by the member was or will be rendered by a provider who is not under 
contract with the Medicare Health Plan. 
 
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 when the hearing aids are obtained through a Plan 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 hearing aids provided by an out-of-network provider have not been met. Therefore, we decided 
that the Plan does not have to pre-approve hearing aids provided by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
May 28, 2023. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you were unable to 
drive. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for ambulance services. 
 
You have been asked to pay a $100 copayment for an ambulance transportation. 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 an 
ambulance transportation provided on May 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided from 
March 18, 2023, to March 20, 2023. 
 
You asked the Plan to waive the deductible for an inpatient hospital stay. You say that you received poor care 
from the hospital. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,600 deductible which applies to inpatient hospital care.  
 
 
 
 
 You have been asked to pay $1,600, which satisfies the deductible for the inpatient hospital stay. The item or 
service you asked the Plan to waive the deductible for falls within the inpatient hospital care benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,600 deductible 
which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at 
the time an inpatient hospital stay was received on March 18, 2023, to March 20, 2023. Therefore, we decided 
that the Plan does not have to waive the deductible for an inpatient hospital stay provided from March 18, 
2023, to March 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplemental over-the-counter (OTC) benefits for past 
benefit periods from January 1, 2023, to August 1, 2023. 
 
You asked the Plan to pay for supplemental OTC benefits for past benefit periods. You say that you were sick 
for four months, where you did not remember to  place an order. The Plan denied your request. The Plan says 
unused benefits do not carry over into the next benefit period. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and 
supplemental OTC benefits for past benefit periods is an OTC item. Therefore, we decided that the Plan does 
not have to pay for supplemental over-the-counter (OTC) benefits for past benefit periods from January 1, 
2023, to August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on May 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. 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 dates of service January 11, 2023, and 
May 8, 2023. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral 
evaluation (D0140) provided on May 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a knee brace and a suspension sleeve 
provided on April 17, 2023. 
 
You asked the Plan to waive the coinsurance for a knee brace and a suspension sleeve. You say that you were 
not informed of the coinsurance. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for a knee brace and a suspension sleeve. 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. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a knee brace and a suspension sleeve provided on April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 11, 2023. 
 
You asked the Plan to pay for lab services. You say that the enrollee has already established care with this 
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 lab services provided on 
April 11, 2023.