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

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that the enrollee is needing to be seen by a 
cerebrovascular surgeon. The Plan denied your request. The Plan says there are other highly qualified 
neurosurgeons in the Seattle area who do cerebrovascular surgery.  
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on May 26, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for physician services. You say that you are requesting reconsideration of the 
referenced claim. The Plan denied your request. The Plan says there is no valid referral for this service. 
 
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 physician services provided on May 26, 2023, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound vacuum and supplies to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve wound vacuum and supplies. You say that this is medically necessary and 
should be covered. The Plan denied your request. The Plan says there are other providers available who are in-
network, who are within the Medicare allowable distance from your residence. 
 
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 
wound vacuum and supplies 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 pay for palliative treatment (D9110) provided on May 8, 2023, and 
June 22, 2023. 
 
You asked the Plan to pay for 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 pay for palliative 
treatment (D9110) provided on May 8, 2023, and June 22, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport, and 
ground mileage provided on January 23, 2023. 
 
You asked the Plan to pay for the ambulance services and ground mileage. You say that the claim should not 
have denied and asks the Plan to review medical records and process claim for payment.  The Plan denied your 
request. The Plan says that our policy covers non-emergency ambulance transportation when it is the only way 
to safely and adequately transport a member or if other means of transporting a member are unsafe due to a 
medical condition. This claim does not meet these requirements.  
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 pay for the ambulance services and ground mileage. 
Our reviewer says that the ambulance transport services were medically necessary. Our physician reviewer 
found the enrollee is bed bound and has profound weakness in extremities making it unsafe to transport the 
enrollee in alternate modes of transportation. Review of the medical records indicate that the enrollee is only 
able to sit up in a wheelchair for a brief period. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services and ground mileage have been met. Therefore, we 
decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport, and ground 
mileage provided on January 23, 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 a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310), intraoral - periapical first radiographic image 
(D0220), cone beam CT capture and interpretation with limited field of view  less than one whole jaw 
(D0364), endodontic therapy, molar tooth (excluding final restoration) (D3330), core buildup, including any 
pins when required (D2950), and unspecified endodontic procedure, by report (D3999) provided on April 3, 
2023. 
 
You asked the Plan to pay for the dental services represented by codes D9310, D0220, D0364, D3330, D2950 
and D3999.  You say that you had to go out of network because there was no endodontist that were in network that could do 
a root canal. 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 a consultation - diagnostic service provided by dentist or physician other than requesting dentist or 
physician (D9310), intraoral - periapical first radiographic image (D0220), cone beam CT capture and 
interpretation with limited field of view  less than one whole jaw (D0364), endodontic therapy, molar tooth 
(excluding final restoration) (D3330), core buildup, including any pins when required (D2950), and unspecified 
endodontic procedure, by report (D3999) provided on April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone services provided on March 17, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for telephone services. You say that the provider states they have submitted medical 
records for medical necessity. The Plan denied your request. The Plan says there is no valid referral for this 
service. 
 
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 telephone services provided on March 17, 2023, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014), a determination of 
refractive state (92015) and fundus photography (92250) provided on February 22, 2023. 
 
You asked the Plan to pay for a medical eye examination (92014), a determination of refractive state (92015) 
and fundus photography (92250). You say that the member informed you there were no changes on his 
insurance 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 a medical eye 
examination (92014), a determination of refractive state (92015) and fundus photography (92250) provided on 
February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 test kits provided on February 21, 2023. 
 
You asked the Plan to pay for COVID-19 test kits. You say that you tested positive for COVID-19 on February 
9, 2023. You also say that you needed to keep testing for several weeks before returning to your regular 
routine, no longer had any free at-home COVID-19 tests, so you purchased two boxes. The Plan denied your 
request. The Plan says At-Home COVID-19 testing kits are not eligible for reimbursement by Medicare or 
Medicare Advantage plans. 
 
  The Plan must follow Medicare rules. Medicare rules say that they will cover up to eight over-the-counter 
COVID-19 tests each calendar month, at no cost to you. Medicare rules also say that enrollees cannot submit a 
claim for these tests to Medicare or their MA plan (unless covered by a supplemental benefit) for 
reimbursement under this initiative.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of COVID-19 test kits have not been met. Therefore, we decided that the Plan does not have to pay 
for COVID-19 test kits provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on March 14, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that the services were rendered in a nursing home 
setting and the enrollee could not choose an in-network provider. 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 nursing facility care 
provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for denture relining services (D5750) provided on April 13, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 April 13, 2023. 
Therefore, we decided that the Plan does not have to pay for denture relining services (D5750) provided on 
April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 9, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are appealing the denial for denied claim. The 
Plan denied your request. The Plan says there is no medical necessity for an out-of-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 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 an office visit provided on January 9, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you saw this provider while hospitalized for 39 
days. The Plan denied your request. The Plan says for Medicare-covered services, if you require specialized 
services that are not available from a provider in our network, contact your Primary Care Physician for 
authorization and coordination of care. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve a specialist office visit. You say that you do not agree with the denial of the 
office visit. The Plan denied your request. The Plan says the service can be provided by an in-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 
a specialist 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 eye examination (92004) and fundus photography (92250) 
provided on January 17, 2023. 
 
You asked the Plan to pay for an eye examination (92004) and fundus photography (92250). You say that you 
do not think these should be denied. You also say no one told you the provider 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 eye examination 
(92004) and fundus photography (92250) provided on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for frames (V2020), sphere bifocal lenses (V2200), 
polycarbonate lenses (V2784) anti-reflective coating (V2750) and tinting (V2744) from an out-of-network 
provider provided on January 17, 2023. 
 
You asked the Plan to reimburse for frames (V2020), sphere bifocal lenses (V2200), polycarbonate lenses 
(V2784) anti-reflective coating (V2750) and tinting (V2744) from an out-of-network provider. You say that 
you do not feel that the claims should be denied. You also say no one told you this provider was out-of-
network. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 they are obtained through a Plan vision provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that a Plan vision provider must be used for vision 
services. The record shows you went to a provider who was not in-network. Based on this information, we 
decided that the Plan's rules for coverage of frames (V2020), sphere bifocal lenses (V2200), polycarbonate 
lenses (V2784) anti-reflective coating (V2750) and tinting (V2744) from an out-of-network provider have not 
been met. Therefore, we decided that the Plan does not have to reimburse for frames (V2020), sphere bifocal 
lenses (V2200), polycarbonate lenses (V2784) anti-reflective coating (V2750) and tinting (V2744) from an out-
of-network provider provided on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on April 27, 2023. 
 
You asked the Plan to pay for an eye refraction (92015). You say that this test was part of an annual eye 
examination, which is covered. The Plan denied your request. The Plan says Original Medicare does not cover 
routine eye examinations (eye refractions) for eyeglasses/contacts. The Plan also says it was confirmed that the 
services received were not for a routine eye exam but rather for nonexudative age-related macular regeneration, 
bilateral, early dry stages according to the providers diagnosis. 
 
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 the eye refraction is part of the routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers outpatient physician services 
for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular 
degeneration. The Plan contract also says that Original Medicare does not cover routine eye exams (eye 
refractions) for eyeglasses/contacts. Based on this information, we decided that the Plan's rules for coverage of 
an eye refraction (92015) have not been met. Therefore, we decided that the Plan does not have to pay for an 
eye refraction (92015) provided on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care services provided on February 1, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care services. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says the enrollee's Plan excludes coverage for this 
out-of-network service. 
 
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 nursing facility care services provided on February 
1, 2023, by an out-of-network (OON) provider.