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

 
We decided that the Plan does not have to pre-approve a neurosurgery consultation to be rendered by an out-of-
network (OON) provider at the in-network benefit level.  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is available with an in-network provider.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The Plan contract says 
that you must receive your care from a network provider to receive the highest level of benefits for covered 
services.  
  
 
 
In most cases, covered services you receive from an out-of-network provider (a provider who is not part of our 
plans network) will be paid at the out-of-network cost sharing with the exception of 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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a 
neurosurgery consultation to be rendered by an out-of-network (OON) provider at the in-network benefit level.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visit. You say that you are requesting authorization for the 
enrollee to see this provider. The Plan denied your request. The Plan says there are network providers that can 
provide these services. 
 
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 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 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 
the office visit to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 26, 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 May 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 7, 2022, to 
September 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 7, 2022, to 
September 5, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H0004 billed for date of service May 9, 
2023. 
 
You asked the Plan to pay for procedure code H0004. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 We find that procedure code H0004 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H0004 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H0004 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H0004 billed for date of service May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 28, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray provided on May 15, 2023. 
 
You asked the Plan to waive the copayment for the chest x-ray. You say that these tests were required before 
the provider would proceed with the surgery. 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 $35 
copayment for in-network outpatient diagnostic tests, including x-rays. 
 
You have been asked to pay a $35 copayment for the chest x-ray. This item/service falls within the in-network 
outpatient diagnostic tests, including x-rays 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. However, since the allowed amount is less than the standard copayment, 
you only owe $31.54. Therefore, we decided that the Plan does not have to waive the copayment for the chest 
x-ray provided on May 15, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve physical therapy. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received 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 
physical therapy 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 pre-approve endosteal implant, custom fabricated abutment, 
abutment supported porcelain/ceramic crown, and pontic (D6058, D6010, D6245, D6057). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental 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 pre-approve 
endosteal implant, custom fabricated abutment, abutment supported porcelain/ceramic crown, and pontic 
(D6058, D6010, D6245, D6057).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network G5 unit with accessories 
provided on January 18, 2023. 
 
You asked the Plan to waive the copayment for an out-of-network G5 unit with accessories. You say that the 
plan didnt contribute anything to this claim. 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 $3586 
copayment for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay a $3586 copayment for an out-of-network G5 unit with accessories. This 
item/service falls within the durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. This was an out-of-network  
provider, therefore, the Plan did not pay towards this claim. Therefore, we decided that the Plan does not have 
to waive the copayment for an out-of-network G5 unit with accessories provided on January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each drug administration service provided 
on May 15, 2023, to June 02, 2023. 
 
You asked the Plan to reduce the copayment for each drug administration service. You say that you were given 
a cost share estimate of $8 coinsurance per date of service from the provider. 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 outpatient surgery. 
 
You have been asked to pay a $95 copayment for each drug administration service. This item/service falls 
within the outpatient surgery 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 are being asked to pay is $285 ($95 copayment per visit x 3 visits = $285). 
Therefore, we decided that the Plan does not have to reduce the copayment for each drug administration service 
provided on May 15, 2023, to June 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vein wound compression bandage 
application provided on May 08, 2023. 
 
You asked the Plan to waive the copayment for the vein wound compression bandage application. You say that 
you needed somebody with advanced wound care training. 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 $360 
copayment for outpatient surgery provided at an outpatient hospital.  
You have been asked to pay a $360 copayment for the vein wound compression bandage application. This 
item/service falls within the outpatient surgery provided at an outpatient hospital 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. However, since the allowed amount is 
less than the standard copayment, you only owe $142.40. Therefore, we decided that the Plan does not have to 
waive the copayment for the vein wound compression bandage application provided on May 08, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on June 15, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
collapsed, 911 was called and you were checked out and advised you could be transported to the hospital. You 
also say that you didn't want your insurance company to incur a hefty emergency bill for the service so you did 
not transfer, and you were unaware of the no transport rule with Medicare. The Plan denied your request. The 
Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 15, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on June 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an echocardiogram provided on June 28, 
2023, and a myocardial perfusion imaging provided on June 29, 2023. 
 
You asked the Plan to waive the copayments for an echocardiogram and a myocardial perfusion imaging. You 
say that you have not had to pay for these services in the past. 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 basic radiology services. Your contract with the Plan also clearly says that you must pay a $295 
copayment for nuclear medicine services. 
 
You have been asked to pay a $95 copayment for an echocardiogram provided on June 28, 2023. You have also 
been asked to pay a $295 copayment for the myocardial perfusion imaging provided on June 29, 2023. You 
have been asked to pay a total of $390 ($95 copayment + $295 copayment = $390). These items/services fall 
within the 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. Therefore, we decided that the Plan does not have to waive the copayments for 
an echocardiogram provided on June 28, 2023, and a myocardial perfusion imaging provided on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration in 
conjunction with periradicular surgery (D3431) for tooth 30 and a computer tomography (CT) scan (D0381) of 
the lower arch. 
 
You asked the Plan to pre-approve biologic materials to aid in tissue regeneration with periradicular surgery 
(D3431) for tooth 30 and a CT scan (D0381) of the lower arch. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says these services are not covered under this 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 pre-approve 
biologic materials to aid in tissue regeneration in conjunction with periradicular surgery (D3431) for tooth 30 
and a computer tomography (CT) scan (D0381) of the lower arch.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an in-network endoscopic procedure 
provided on May 26, 2023. 
 
You asked the Plan to reduce the copayment for an in-network endoscopic procedure. You say that you thought 
this would be an office visit copayment. No one prepared you that you would have this substantial 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 $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $325 copayment for an in-network endoscopic procedure. This item/service falls 
within the 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 reduce the copayment for an in-network endoscopic 
procedure provided on May 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on May 5, 2023. 
 
You asked the Plan to pay for the refraction. You say that you were told that your yearly eye exam was billed 
as a 'medical exam' than a routine eye exam.  The Plan denied your request. The Plan says the service was not a 
covered 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 these services when performed as a part of a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we 
decided that the Plan does not have to pay for the refraction provided on May 5, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an in-network emergency room (ER) visit 
provided on July 07, 2023, to July 08, 2023. 
 
You asked the Plan to reduce the copayment for an in-network emergency room (ER) visit. You say that you 
have a chronic heart condition and feel this copay should be lowered to reflect 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an in-network 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 reduce the copayment for 
an in-network emergency room (ER) visit provided on July 07, 2023, to July 08, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on May 17, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you do not remember receiving any drugs 
during your visit and feel you should not be required to pay so much for medication. The Plan denied your 
request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on May 17, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.