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

 
We decided that the Plan does not have to pay for the outpatient hospital visit provided on July 05, 2023. 
 
You asked the Plan to pay for the outpatient hospital visit. 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 the outpatient hospital 
visit provided on July 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services, the preventative care services, and 
the dialysis procedures provided on June 02, 2023, to June 30, 2023. 
 
You asked the Plan to pay for the laboratory services, the preventative care services, and the dialysis 
procedures. You say that you are requesting reconsideration of the denied claim. The Plan denied your request. 
The Plan says that unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services, 
the preventative care services, and the dialysis procedures provided on June 02, 2023, to June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for refraction provided on July 13, 2023. 
 You asked the Plan to pay for refraction. You say that you are requesting reconsideration for the denied claim. 
The Plan denied your request. The Plan says it is not covered under your contract under any normal 
circumstances. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for refraction provided on July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Lite blood glucose test strips. 
 
You asked the Plan to pre-approve the FreeStyle Lite blood glucose test strips. You say that this service is 
medically necessary. The Plan denied your request. The Plan says the details we received dont meet the 
Medicare guidelines that show a medical reason the enrollee needs the  FreeStyle Lite glucose test strips. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to certain brands of 
products and this plan only covers Ascencia's Contour and Johnson & Johnson's Lifescan OneTouch products.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the FreeStyle Lite blood glucose test strips have not been met. Therefore, we decided that the Plan 
does not have to pre-approve FreeStyle Lite blood glucose test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a covid-19 test provided on August 16, 2023. 
 
You asked the Plan to pay for a covid-19 test. You say that the referring provider is required to verify network 
status. 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 covid-19 test provided 
on August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on June 28, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. 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 a hospital outpatient 
clinic visit provided on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate lower denture (D5140), and an alveoloplasty not 
in conjunction with extractions (D7320) provided on June 2, 2022. 
 
You asked the Plan to pay for immediate lower denture and an alveoloplasty. 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 
immediate lower denture (D5140), and an alveoloplasty not in conjunction with extractions (D7320) provided 
on June 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the soft tissue of 
the neck without contrast. 
 
You asked the Plan to pre-approve the CT scan. You say that the scan will help improve your medical health. 
The Plan denied your request. The Plan says a picture study taken without dye will not show your doctor all the 
details they need in order to treat you. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 the CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found medical necessity of the requested CT scan 
of the neck is not demonstrated in the medical records submitted. The CT scan cannot be approved at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the soft tissue of the neck without contrast.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy with an injection (45381) 
provided on June 22, 2023. 
 
You asked the Plan to waive the copayment for the colonoscopy with an injection. You say that you would like 
the $400 charge to be waived to make your balance $0.00. 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 $400 
copay for outpatient procedures under the outpatient hospital services benefit category.  
 
 You have been asked to pay a $400 copay for the colonoscopy with an injection. This item/service falls within 
the outpatient hospital services benefit category. Specifically, this colonoscopy was not a screening because the 
record shows that a polyp was found and injected with saline, making it a surgical procedure. 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 colonoscopy with an injection (45381) provided on June 22, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network knee injection provided on 
May 11, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network knee injection. You say that you were not told 
that there would be a coinsurance for this treatment. 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 an in-network knee 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 $81.24 ($406.20 x 20% = $81.24). Therefore, we 
decided that the Plan does not have to waive the coinsurance for an in-network knee injection provided on May 
11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for eye injections provided from August 24, 
2022, to May 31, 2023. 
 
You asked the Plan to waive the copayments for eye injections. 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 $30 
copayment for exams to diagnose and treat diseases and conditions of the eye.  
 
 
  You have been asked to pay a $150 copayment for eye injections ($30 per visit x 5 visits = $150). 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 copayments 
for eye injections provided from August 24, 2022, to May 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
October 27, 2022, to November 02, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 $295 
copayment for inpatient hospital care. 
 
You have been asked to pay a $295 copayment for the inpatient hospital 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. You have been asked to pay a total of $1,770 for the inpatient hospital stay ($295 
copayment x 6 days = $1,770). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on October 
27, 2022, to November 02, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy provided on August 
22, 2023. 
 
You asked the Plan to waive the copayment for occupational therapy. You say that you should not be 
responsible to pay this. 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 $30.00 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $30.00 copayment for occupational therapy. This item/service falls within the 
outpatient rehabilitation 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 
occupational therapy provided on August 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each debridement procedure provided on 
June 07, 2023, to July 05, 2023. 
 
You asked the Plan to waive the copayment for each debridement procedure. You say that you were not told 
that you would have a 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 $200 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $200 copayment for each debridement procedure. This item/service falls within 
the in-network outpatient hospital 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. The total amount you owe is $800 ($200 copayment x 4 procedures = 
$800). Therefore, we decided that the Plan does not have to waive the copayment for each debridement 
procedure provided on June 07, 2023, to July 05, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support (A0429) provided on July 17, 
2023. 
 
You asked the Plan to pay for ambulance service, basic life support (A0429). You say that the first transport 
occurred at 3:18 AM from a place of business to the hospital for anxiety. You also say that the second transport 
occurred at 7:42 PM from a place of business to the hospital for edema. The Plan denied your request. The Plan 
says that this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The duplicate claim is not supported because the 
record shows the times were two different times and the reasoning for the transports are not the same The 
record shows these are two separate transports. Based on this information, we decided that Medicare rules for 
coverage of ambulance service, basic life support (A0429) have been met. Therefore, we decided that the Plan 
has to pay for ambulance service, basic life support (A0429) provided on July 17, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for placement of intra-socket biological dressing to aid in 
hemostasis or clot stabilization per site (D7922 x7) and therapeutic injection of medicine, single dose (D9610 
x5) provided on July 17, 2023. 
 
You asked the Plan to pay for these dental services. 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 placement 
of intra-socket biological dressing to aid in hemostasis or clot stabilization per site (D7922 x7) and therapeutic injection of medicine, single dose (D9610 x5) provided on July 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection and infusion services provided on August 11, 2023. 
 
You asked the Plan to pay for injection and infusion services. You say that you are requesting reconsideration 
for the denied claim. The Plan denied your request. The Plan says they cannot determine how the enrollee came 
to the servicing provider, whether the services were performed as billed, or whether the services are medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of injection and infusion services have 
been met. No supporting medical records were submitted to prove that the services billed on this claim actually 
occurred. Therefore, we decided that the Plan does not have to pay for injection and infusion services provided 
on August 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on June 21, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you are asking for a reconsideration of the 
denied calim. 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 skilled nursing facility 
provided on June 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an in-network gastric procedure provided 
on June 07, 2023. 
 
You asked the Plan to reduce the copayment for an in-network gastric procedure. You say that you were only 
charged an office visit charge in the past for this. Why is this copayment so high now? 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 outpatient hospital visits. 
 
You have been asked to pay a $350 copayment for an in-network gastric procedure. This item/service falls 
within the outpatient hospital visits 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 
an in-network gastric procedure provided on June 07, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation services to your upcoming appointments. 
 
You asked the Plan to pre-approve the transportation services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 The services you have asked the Plan to pre-approve are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pre-approve transportation services to your upcoming 
appointments.