Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the limited oral evaluation - problem 
focused (D0140) provided on June 19, 2023. 
 
You asked the Plan to waive the coinsurance the limited oral evaluation - problem focused. You say that you 
picked the first provider listed in the directory and this provider was listed as participating.   The Plan denied your request. The Plan says the claim was reprocessed to pay at the in-network benefit level 
and the coinsurance was appropriately applied. 
 
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 Plan contract says you 
pay 50% coinsurance after $100 deductible has been met for all Class 2 Basic services, such as limited oral 
evaluations. 
 
You have been asked to pay $46.50, which is 50% of the allowed amount for the limited oral evaluation. The 
allowed amount for this service is $93.00, leaving you responsible for $46.50 cost-share responsibility (50% of 
$93.00 = $46.50). 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 coinsurance for the limited oral evaluation - 
problem focused provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services (99214) provided on January 3, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit services (99214) provided by an OON provider. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services provided were not emergent, urgent, or routine dental services. The Plan says there were in-network 
providers available to the enrollee. 
 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 the office visit services (99214) provided on 
January 3, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the outpatient surgery provided on July 07, 
2023. 
 
You asked the Plan to reduce the copayment for the outpatient surgery. You say that you are asking for the plan 
to adjust the copay to $100. 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 outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $295 copayment for the outpatient surgery. This item/service falls within the 
outpatient surgery and other medical 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. 
However, since the allowed amount is less than the standard copayment, you only owe $256.08. Therefore, we 
decided that the Plan does not have to reduce the copayment for the outpatient surgery provided on July 07, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350 x3) and re-
evaluation - post-operative office visit (D0171) provided on August 9, 2023, to August 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the 2D oral/facial photographic images 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 2D oral/facial photographic images was exhausted on date of service August 9, 2023. Therefore, we decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350 
x3) and re-evaluation - post-operative office visit (D0171) provided on August 9, 2023, to August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on June 1, 2023. 
 
You asked the Plan to pay for the hearing aids. You say that you attempted to sue the network hearing provider, 
but they did not offer any behind-the-ear aid. You say this is not suitable for your hearing loss situation. The 
Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only received through the network provider.  
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of the hearing aids have not been met. Specifically, the provider was out-of-
network. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on June 1, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF services provided from May 1, 2023, to May 31, 
2023. 
 
You asked the Plan to pay for the SNF services. You say that you are asking for a one-time exception and 
could not file the claim on time due to multiple hardships. The Plan denied your request. The Plan says the 
claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the SNF services was not filed until August 25, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the SNF services provided from May 1, 2023, to May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network computed tomography (CT) 
chest scan provided on July 25, 2023. 
 
You asked the Plan to waive the copayment for an in-network computed tomography (CT) chest scan. You say 
that you cannot afford these copayments, you are filing for bankruptcy. 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 $250 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $250 copayment for an in-network computed tomography (CT) chest scan. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and 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. However, since the 
allowed amount is less than the standard copayment, you only owe $151.52. Therefore, we decided that the 
Plan does not have to waive the copayment for an in-network computed tomography (CT) chest scan provided 
on July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on August 
19, 2023. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you are appealing the claim 
payment denial. 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 chiropractic 
manipulative treatment provided on August 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) 
service provided on August 15, 2023. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) service. You say that your 
primary care provider told you to go to the ER, all they did was take some blood. You feel you should not have 
to pay. 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 $110 
copayment for emergency services. 
 
You have been asked to pay a $110 copayment for an in-network emergency room (ER) service. This 
item/service falls within the emergency 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 in-network emergency room (ER) service provided on August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
June 16, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you say that the 
hospital staff told you to dispute the bill. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for the emergency room services. 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 emergency room 
services provided on June 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that the requested provider is closest to your 
house. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider. 
 
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 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on August 5, 
2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for physician services. You say that the enrollee was residing in a nursing facility at 
the time of service. The Plan denied your request. The Plan says that their original decision to deny payment 
was correct. 
 
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 principal care management services provided on 
August 5, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on July 26, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary, please review 
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 laboratory testing 
provided on July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each interrogation device evaluation 
provided on September 08, 2022, to December 08, 2022. 
 
You asked the Plan to waive the copayment for each interrogation device evaluation. You say that you cannot 
afford the two copayments. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for in-network diagnostic tests in a specialty physicians office. 
 
You have been asked to pay a $20 copayment for each interrogation device evaluation. This item/service falls 
within the in-network diagnostic tests in a specialty physicians office 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 $40 ($20 
copayment x 2 services = $40). Therefore, we decided that the Plan does not have to waive the copayment for 
each interrogation device evaluation provided on September 08, 2022, to December 08, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 16, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary and should be 
covered. This patient was confused by her coverage. 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 August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on June 27, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that you are appealing the denial with 
supporting documentation. 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 wound care supplies 
provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network primary care provider (PCP) 
visit provided on July 12, 2023. 
 
You asked the Plan to waive the deductible for a primary care visit. You say that you need assistance with your 
deductible, you feel you can never pay for it fully in a 12 month period. 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. Your 
contract with the Plan says that there is a $226 deductible which applies to physician/practitioner services, 
including doctors office visits. Youre being asked to pay $148.07 towards this deductible for 2023. 
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $226 deductible which applies to physician/practitioner services, 
including doctors office visits.  This cost sharing is a contractual obligation that had not been met at the time a primary care visit was received 
on July 12, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an in-network 
primary care provider (PCP) visit provided on July 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93005 provided on February 27, 2023. 
 
You asked the Plan to pay for procedure code 93005. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that codes with a status indicator of Q1 are not 
separately payable.  
We find that CPT code 93005 is a packaged service due to being billed on the same claim as code 99285, 
which has a status indicator of V. Based on this information, we decided that Medicare rules for coverage of 
procedure code 93005 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 93005 provided on February 27, 2023.