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

 
We decided that the Plan does not have to pay for an office visit provided on July 13, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services provided on September 26, 2022. 
 
You asked the Plan to pay for physicians services. You say that the services were medically necessary. 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 physicians services 
provided on September 26, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
July 13, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you disagree with 
the cost share applied. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency 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 emergency room 
(ER) visit provided on July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care, and related services provided on 
May 17, 2023. 
 
You asked the Plan to pay for initial nursing facility care, and related services. You say that the enrollee was in 
a nursing home setting at the time 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 initial nursing facility 
care, and related services provided on May 17, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on April 
05, 2023, to April 26, 2023. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that you do not agree with the 
copayment assessed for the services. 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 $196 
copayment for skilled nursing facility (SNF) care. 
 
You have been asked to pay a $196 copayment for skilled nursing facility. This item/service falls within the skilled nursing facility (SNF) 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. You have been asked to pay a $1917.29 copayment; which is less than the total 
amount for the skilled nursing facility stays. Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility provided on April 05, 2023, to April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the podiatry services on June 28, 2023. 
 
You asked the Plan to waive the cost share for the podiatry services. You say that you want to know why you 
are being charged more than $10.00. 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 $25 
copayment for each Medicare-covered visit in an office or home setting. A payment of $10 was made. For the 
service it's $20.05 - $10 = $10.05. Therefore, results in the total cost sharing amount of $10.05. 
 
You have been asked to pay a $10.05 cost share for the podiatry services. This item/service falls within the 
podiatry 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 cost share for the podiatry services 
on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services rendered were 
medically necessary. 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 subsequent nursing 
facility care provided on June 15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
21, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you do not agree with the 
copayment assessed. 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 $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for the ambulance services. 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 the ambulance 
services provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote patient monitoring provided on July 18, 2023. 
 
You asked the Plan to pay for remote patient monitoring. You say that this service was medically necessary. 
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 remote patient 
monitoring provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3D conformal radiation therapy. 
 
You asked the Plan to pre-approve 3D conformal radiation therapy. You say that it is medically necessary. The 
Plan denied your request. The Plan says you are asking to give the enrollee 32 treatments (fractions). A medical 
need for this request has not been shown. Using this many number of treatments for the enrollee's cancer is not 
supported. Giving too much treatment will not help the enrollee's cancer.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 3D conformal radiation therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found national consensus guidelines do not suggest that hypofractionation is 
necessary over standard fractionation, and with a large lesion (albeit not in cosmetically sensitive area or abutting cartilage). Therefore, 32 fractions would be within accordance with accepted standards of medical 
practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3D conformal radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 3D conformal radiation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-periapical each additional image (D0230 x4), 
intraoral-periapical first radiographic image (D0220), core buildup (D2950), unspecified restorative procedure 
(D2999) and a crown-porcelain/ceramic (D2740) provided on March 28, 2023, to April 4, 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 intraoral-periapical images and the crown has already been 
exhausted. A core buildup and unspecified restorative procedure are not covered services. 
 
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 crown was exhausted on date of service September 20, 2018. Therefore, we decided that 
the Plan does not have to pay for intraoral-periapical each additional image (D0230 x4), intraoral-periapical 
first radiographic image (D0220), core buildup (D2950), unspecified restorative procedure (D2999) and a 
crown-porcelain/ceramic (D2740) provided on March 28, 2023, to April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for gingival flap procedure, including root planing four or more 
contiguous teeth or tooth bounded spaces per quadrant (D4240) and gingival flap procedure, including root 
planing - one to three contiguous teeth or tooth bounded spaces per quadrant (D4241) provided on July 12, 
2023. 
 
You asked the Plan to pay for gingival flap procedures. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 gingival 
flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant 
(D4240) and gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded 
spaces per quadrant (D4241) provided on July 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable chest x-ray provided on May 26, 2023. 
 
You asked the Plan to pay for a portable chest x-ray. You say that this service was medically necessary. 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 chest x-ray 
provided on May 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lens fitting (92310) and contact lenses (V2599) 
provided on July 18, 2023. 
 
You asked the Plan to pay for contact lens fitting (92310) and contact lenses (V2599). You say that 
unfortunately, there are no predictive indicators as to what rate the corneal shape will change with corneal 
ectasia, for which you are being treated. You also say that thus, the imposition or an arbitrary time interval for 
reimbursement for treatment of this eye disease is inappropriate and may create a risk for you. The Plan denied 
your request. The Plan says this benefit has been exhausted. 
 
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 one pair of standard lenses and frames or contact lenses every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say the Plan coverage is limited to one pair of 
standard lenses and frames or contact lenses every two years. The record shows this benefit was exhausted on 
July 14, 2022. Based on this information, we decided that the Plan's rules for coverage of contact lens fitting 
(92310) and contact lenses (V2599) have not been met. Therefore, we decided that the Plan does not have to 
pay for contact lens fitting (92310) and contact lenses (V2599) provided on July 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable knee x-rays provided on May 06, 2023. 
 
You asked the Plan to pay for portable knee x-rays. You say that this is supported in the records. 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 portable knee x-rays 
provided on May 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for pulp vitality tests (D0460), cone beam CT image 
(D0380), limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image 
(D0220) provided on June 1, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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. Pulp vitality tests and a cone beam CT 
image are not covered services. 
 
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 pulp vitality tests (D0460), cone beam CT 
image (D0380), limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic 
image (D0220) provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair recurrent inguinal hernia provided on April 17, 2023. 
 
You asked the Plan to pay for repair recurrent inguinal hernia. You say that the services were medically 
necessary 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 repair recurrent inguinal 
hernia provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a special eye evaluation (92060) provided on April 21, 2023.  
You asked the Plan to pay for a special eye evaluation (92060). You say that you have had the same 
examination for years. You also say the examinations have always been covered. The Plan denied your request. 
The Plan says this service is not covered under your benefit. 
 
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 one routine eye examination per calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover one routine eye examination (includes 
refraction) per calendar year. A special eye evaluation (92060) is not covered under this benefit. Based on this 
information, we decided that the Plan's rules for coverage of a special eye evaluation (92060) have not been 
met. Therefore, we decided that the Plan does not have to pay for a special eye evaluation (92060) provided on 
April 21, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on July 
12, 2023. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. 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 $20 
copayment for outpatient diagnostic tests/Medicare-coverednon-radiological diagnostic services. 
 
You have been asked to pay a $20 copayment for outpatient diagnostic tests. This item/service falls within the 
outpatient diagnostic tests/Medicare-coverednon-radiological diagnostic 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 outpatient diagnostic tests provided on July 12, 2023.