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

 
We decided that the Plan does not have to pay for comp assessment provided on March 16, 2023, by an out-of-
network (OON) provider.  
 
 You asked the Plan to pay for comp assessment. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 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 comp assessment provided on March 16, 2023, by 
an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services, and the emergency 
department visit provided on February 17, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services, and the emergency department visit. 
You say that you do not think you should be responsible for 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 $260 
copayment per Medicare-covered one-way ambulance transport, and a $90 copayment per visit for emergency 
care. You have been asked to pay a $260 copayment for the ambulance services. These items/services fall within the 
ambulance services benefit category. You have also been asked to pay a $90 copayment for the emergency 
department 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 the ambulance services, and the emergency department visit provided on February 
17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and a secondary membranous cataract 
procedure provided on April 12, 2023. 
 
You asked the Plan to pay for an office visit, and a secondary membranous cataract procedure. 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 an office visit, and a 
secondary membranous cataract procedure provided on April 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the placement of a breast localization 
device provided on April 25, 2023. 
 
You asked the Plan to waive the copayment for the placement of a breast localization device. You say that you 
do not think you should be responsible for this 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 $50 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $50 copayment for the placement of a breast localization device. This 
item/service falls within the in-network outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 placement of a breast localization device provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on March 13, 2023. 
 
You asked the Plan to pay for the podiatry services. You say that you are requesting reconsideration for the 
denied payment. 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 podiatry services 
provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the destruction of premalignant lesions 
provided on April 10, 2023. 
 
You asked the Plan to waive the copayment for the destruction of premalignant lesions. You say that you do 
not agree 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 $45 
copayment for each specialist visit for Medicare-covered services. 
 
You have been asked to pay a $45 copayment for the destruction of premalignant lesions. This item/service 
falls within the each specialist visit for Medicare-covered 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 destruction of premalignant lesions provided on April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an allergen immunotherapy injection 
provided on March 31, 2023. 
 
You asked the Plan to waive the coinsurance for an allergen immunotherapy injection. You say that you 
thought that this service would be fully covered. 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 in-network chemotherapy drugs, and all other drugs covered under Medicare Part B. 
 
You have been asked to pay 20% coinsurance for an allergen immunotherapy injection. This item/service falls within the in-network chemotherapy drugs, and all other drugs covered under Medicare Part B 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 $1.72 
($8.60 allowed amount x 20% = $1.72). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an allergen immunotherapy injection provided on March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on March 01, 2023. 
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 home visit provided on 
March 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 22, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the denied 
payment. The Plan denied your request. The Plan says the services were 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on February 22, 2023, by 
an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
November 22, 2021, to December 11, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that it is over one year since 
your husband passed away. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $150 copayment per day for days 1-5 of each in-network inpatient hospital stay. The enrollees contract with the Plan also clearly says that enrollees then pay a $0 copayment per day for days 6-90 of each in-
network inpatient hospital stay. 
 
The enrollee has been asked to pay a $150 copayment per day for days 1-5 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. The enrollee has not been asked to pay 
after day five or for the day they were discharged. The enrollee has been asked to pay a total of $750 for the 
inpatient hospital stay ($150 copayment per day x 5 days = $750). This means that the enrollee has been asked 
to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the inpatient hospital stay provided from November 22, 2021, to December 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 
10, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this service was a post 
operative follow-up visit. 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 $45 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
in-network physician/practitioner services, including doctors office 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. The record shows that services were 
rendered outside the global period for the procedure. Therefore, we decided that the Plan does not have to 
waive the copayment for the specialist office visit provided on April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 21, 2023. 
 
You asked the Plan to pay for the physician's services. You say that you purchased this policy specifically for 
the Naturopathic benefits. The Plan denied your request. The Plan says the service(s) rendered is excluded from 
the member's out-of-network benefit plan. 
 
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan pays for the 
services of a naturopath only with a Plan provider. 
 
We looked at the file and the Plans rules. The file shows that you did not use a Plan provider for the services. 
Based on this information, we decided that the Plans rules for coverage of the physician's services have not 
been met. Therefore, we decided that the Plan does not have to pay for physician's services provided on 
January 21, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the telemedicine visit provided on February 3, 2023. 
 
You asked the Plan to waive the copayment for the telemedicine visit. You say that this was not an in person 
visit. The Plan denied your request. The Plan says that 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 enrollees pay a $0 copayment for each covered e-visit or virtual check-in with 
their primary care provider (PCP), other primary care provider, or a specialist. 
 
The Plan says you must pay a $40 copayment for the telemedicine visit. Based on the Plan contract, however, 
you cannot be asked to pay any cost sharing for the telemedicine visit. Therefore, we decided that the Plan has 
to waive the copayment for the telemedicine visit provided on February 3, 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 an extraction (D7140) and the surgical removal of an erupted 
tooth (D7210) for tooth #30 and #31 provided by an out-of-network provider on March 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you did not realize that the oral surgeon was 
out-of-network and there were no close in-network providers that could provide the dental services to the 
enrollee. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. Also, it was verified that there are multiple in-
network providers available in the enrollee's service area. 
 
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. 
 
  The record shows the enrollee received the requested dental services from an out-of-network provider. Though 
the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered 
under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for an extraction (D7140) and the surgical removal of an erupted tooth (D7210) for tooth #30 and 
#31 provided by an out-of-network provider on March 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment-includes placement for 
tooth number 29 (D6057) and an abutment supported porcelain fused to metal crown (high noble metal) for 
tooth number 29 (D6059). 
 
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 has already been exhausted.   
 
 
 
 
Specifically, the Plans contract states that up to two dental implants are covered per year. The Plan previously 
approved dental implants for teeth number 19 and 20. Therefore, you have exhausted the allowable benefit for 
the requested dental items at this time. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated abutment-includes placement for tooth number 29 (D6057) and an abutment supported 
porcelain fused to metal crown (high noble metal) for tooth number 29 (D6059).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bupivacaine (J3490). 
 
You asked the Plan to pay for the medication. You say that this should be covered. The Plan denied your 
request. The Plan says this medication is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Bupivacaine when administered for chronic pain 
control is not covered by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medication have not been met. Therefore, we decided that the Plan does not have to pay for 
Bupivacaine (J3490).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body (D6010) and an 
extraction (D7140) for tooth #6 provided on November 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that implants would be covered 
after a 24-month waiting period and you would have waited to get the procedures done. The Plan denied your 
request. The Plan says the denial of payment for these services is correct because implants and tooth 
extractions are not covered by the Plan. Also, it was verified that no misinformation was given to you about 
your dental coverage. 
 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 the 
surgical placement of implant body (D6010) and an extraction (D7140) for tooth #6 provided on November 10, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the endodontic therapy 
(D3332) for tooth #18 provided on December 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were an emergency because 
you were in extreme pain. The Plan denied your request. The Plan says your benefit for the limited oral 
evaluation has already been exhausted. Also, the endodontic therapy is not covered by the Plan. 
 
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 limited oral evaluation was exhausted on the date of service of December 28, 2022. 
The endodontic therapy is not covered under the Plans dental benefit. Therefore, we decided that the Plan does 
not have to pay for a limited oral evaluation (D0140) and the endodontic therapy (D3332) for tooth #18 
provided on December 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement provided on April 20, 2023. 
 
You asked the Plan to pay for the debridement. You say that you are requesting reconsideration due to medical 
necessity. 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 debridement 
provided on April 20, 2023.