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

 
We decided that the Plan does not have to pay for a therapeutic procedure provided on August 29, 2022. 
 
You asked the Plan to pay for a therapeutic procedure. You say that you are requesting reconsideration for the 
services provided. 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 therapeutic procedure 
provided on August 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for in-network chemotherapy treatment 
provided on July 31, 2023. 
 
You asked the Plan to reduce the coinsurance for in-network chemotherapy treatment. You say that this 
treatment was ten times the amount it usually is. If you had known about this change, you would have looked 
for an alternative. 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 in-network chemotherapy treatment. 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 $2,354.60 ($11,773.02 x 20% = $2,354.60). Therefore, 
we decided that the Plan does not have to reduce the coinsurance for in-network chemotherapy treatment 
provided on July 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on July 07, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this patient is in a facility, and you depend upon the 
facility staff for any verification or 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 July 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lesion destruction procedure, the biopsy, and the office 
visit provided on June 28, 2023. 
 
You asked the Plan to pay for a lesion destruction procedure, the biopsy, and the office visit. You say that you 
are requesting reconsideration of the denied claim. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a lesion destruction 
procedure, the biopsy, and the office visit provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on July 06, 2023. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you say that at the time of service the 
member was residing at a nursing and rehabilitation center and was not responsible to obtain authorization. The 
nursing home is responsible to obtain prior authorization for all 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 skilled nursing facility 
care provided on July 06, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on May 31, 2023. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you feel that the medication 
should be the same price. 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 chemotherapy. 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 $826.81 ($4,134.06 allowed amount x 20% = $826.81). Therefore, 
we decided that the Plan does not have to waive the coinsurance for chemotherapy provided on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and panoramic 
imaging (D0330) provided on February 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay more for this. 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 date of service February 24, 2023. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and 
panoramic imaging (D0330) provided on February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 29, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary and should be 
covered. 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 laboratory services 
provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided on June 5, 2023. 
 
You asked the Plan to pay for D2950. You say that you needed this dental work. The Plan denied your request. 
The Plan says the denied dental service is not a covered benefit. 
 
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 a core 
build-up (D2950) provided on June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6752) and pontics (D6242) provided on 
June 1, 2023. 
 
You asked the Plan to pay for D6752 and D6242. You say that you were told this would be covered with a 50% 
coinsurance. The Plan denied your request. The Plan says the rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a retainer 
crown (D6752) and pontics (D6242) provided on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on April 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 date of service December 15, 2022. 
Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 05, 2023. 
 
You asked the Plan to pay for an office visit. You say that you say that you were not aware that the doctor was 
out-of-network. 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 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on June 14, 2023. 
 
You asked the Plan to pay for a home visit. 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 home visit provided on 
June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
November 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you will not pay for this. 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 date of service January 17, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
March 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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.  
 
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 you 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 dental services provided by an out-of-network provider on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on July 11, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this patient is in a facility, and you depend upon the 
facility staff for any verification or 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 July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 12, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion device (E0936). 
 
You asked the Plan to pre-approve a continuous passive motion device. You say that the item is necessary. The 
Plan denied your request. The Plan says the requested item is not covered for patients that have had shoulder 
surgery. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion device (E0936).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transportation provided on 
June 16, 2023. 
 
You asked the Plan to waive the copayment for an ambulance transportation. You say that you did not receive 
transportation 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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 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 June 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 09, 2023. 
 
You asked the Plan to pay for lab testing. You say that you say that services are covered and provided medical 
records for review. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
June 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for crowns (D2740) for tooth #9 and #30, and resin-based 
composites (D2393 and D2332) provided on June 19, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you believe that the Plan should pay for 
this. 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.  
 
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. Evidence was provided to show that D2740 for tooth #30 was provided on January 11, 2023. Therefore, we 
decided that the Plan does not have to pay more for crowns (D2740) for tooth #9 and #30, and resin-based 
composites (D2393 and D2332) provided on June 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve a Freestyle Libre 2 sensor kit. You say that the services are necessary. The 
Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a Freestyle Libre 2 sensor kit. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre 2 sensor kit.