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

 
We decided that the Plan does not have to pay for telephone service provided on May 18, 2023. 
 
You asked the Plan to pay for telephone service. You say that you are requesting reconsideration for 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 telephone service 
provided on May 18, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 25, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations, and the date of the 
consultations in the patient's medical record. There was not documentation of contact in the patient record. The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on April 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine transportation trips provided on June 13, 2023. 
 
You asked the Plan to pay for the additional trips. You say that this claim should be covered. The Plan denied 
your request. The Plan says the benefit has been exhausted. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
The record shows there were 24 one-way trips received between January 9, 2023, and May 4, 2023. Based on 
this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pay for routine transportation trips 
provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067) and the take home 
supply of methadone (G2078) provided on May 15, 2023, by an OON provider.  
 
You asked the Plan to pay for the medication assisted treatment and the take home supply of methadone. You 
say that you are requesting reconsideration of the denied claim. The Plan denied your request. The Plan says 
the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 medication assisted treatment (G2067) and the 
take home supply of methadone (G2078) provided on May 15, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), bifocal lenses (V2200), and vision supplies 
or accessories (V2797) provided on June 8, 2023. 
 
You asked the Plan to pay for frames (V2020), bifocal lenses (V2200), and vision supplies or accessories 
(V2797). You say that at the time you were told that you were covered by the Plan and only owed the taxes. 
The Plan denied your request. The Plan says the Plan does not cover these out-of-network vision care 
services/materials 
 
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 eyeglasses are obtained through an in-network vision 
provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that any benefits received at a non-network optical 
provider are excluded from this benefit. Based on this information, we decided that the Plan's rules for 
coverage of frames (V2020), bifocal lenses (V2200), and vision supplies or accessories (V2797) have not been 
met. Therefore, we decided that the Plan does not have to pay for frames (V2020), bifocal lenses (V2200), and 
vision supplies or accessories (V2797) provided on June 8, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the extraspinal chiropractic manipulative treatments (98943 x 4) 
provided from May 12, 2022, through May 31, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the enrollee has exhausted the allowable 
benefit for the services provided in this case.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that the enrollee has exhausted the allowable 
benefit for the services provided in this case. However, the Plans contract states that 30 visits each calendar 
year with a licensed chiropractor for additional services beyond the Medicare benefit are covered. The record 
shows that only 26 chiropractic visits were previously provided. The Plan has not substantiated their denial; 
therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the extraspinal 
chiropractic manipulative treatments (98943 x 4) provided from May 12, 2022, through May 31, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional retainer crown (D6752) provided on February 
16, 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 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 16, 2023. 
Therefore, we decided that the Plan does not have to pay for an additional retainer crown (D6752) provided on 
February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maintenance therapy provided by a chiropractor on May 
15, 2023. 
 
You asked the Plan to pay for the maintenance therapy. You say that this service should be covered. The Plan 
denied your request. The Plan says that anything other than manual manipulation of the spine to correct 
subluxation is not covered under any condition. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the maintenance therapy provided by a chiropractor on May 15, 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 September 20, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
not be held liable when it was the store who called the ambulance, not you. 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 September 20, 2022. 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 September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incisional biopsy of oral tissue-soft (D7286) provided on 
April 29, 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 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 July 26, 2023. Therefore, 
we decided that the Plan does not have to pay for an incisional biopsy of oral tissue-soft (D7286) provided on 
April 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92004) and a determination of 
refractive state (92015) provided on June 14, 2023.  
You asked the Plan to pay for a medical eye examination (92004) and a determination of refractive state 
(92015). You say that the Plan representative recommended this provider. The Plan denied your request. The 
Plan says the out-of-network copayment for a routine eye examination covers $75. The Plan also says that the 
EOC states the member is responsible for any amount over $75. 
 
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 an eye examination, but you are responsible for any amount over $75. 
 
We looked at the file and the Plan's rules. The Plan rules say that you pay any amount over $75 for a routine 
eye examination. Based on this information, we decided that the Plan's rules for coverage of a medical eye 
examination (92004) and a determination of refractive state (92015) have not been met. Therefore, we decided 
that the Plan does not have to pay for a medical eye examination (92004) and a determination of refractive state 
(92015) provided on June 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
from February 25, 2023, to February 28, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you were told 
by the nursing staff that your plan would cover this stay. 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 per day, days 1-5 for inpatient hospital care.  
 
You were in the hospital for 3 days, resulting in a $750 total copayment ($250 x 3 = $750). However, you are 
being asked to pay $736.99, which is less than the full copayment.  
You have been asked to pay a $736.99 total copayment for an in-network acute inpatient stay. This item/service 
falls within the inpatient hospital 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 
an in-network acute inpatient stay provided from February 25, 2023, to February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incomplete endodontic therapy (D3332) provided on April 
18, 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 
incomplete endodontic therapy (D3332) provided on April 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a PET scan provided on July 3, 2023. 
 
You asked the Plan to waive the cost share for a PET scan. You say that you do not understand why you are 
responsible for a copayment if the procedure was approved. 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, 20% coinsurance for each Medicare-covered medical 
supply, and a $50 copayment for Medicare-covered radiological diagnostic services.  
 
You have been asked to pay $282.75 for a PET scan. This total includes $189.55 coinsurance, which is 20% of 
the allowed amount for the Medicare Part B prescription drug used during the scan ($947.77 allowed x 20% = 
$189.55), a $50 copayment for a radiological diagnostic service, and $43.20 coinsurance, which is 20% of the 
allowed amount for a medical supply used during the procedure ($216 allowed x 20% = $43.20). 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. Therefore, we decided that the Plan does not have 
to waive the cost share for a PET scan provided on July 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an alveoloplasty and dentoalveolar structures (41874, 41899) 
provided on April 26, 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 the enrollees plan benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for an 
alveoloplasty and dentoalveolar structures (41874, 41899) provided on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination provided on May 30, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an eye examination. You say that since most of the patients in the nursing home 
setting require urgent care, it is not possible to request authorization before services are rendered. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan. 
 
  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 at issue in this case is not a network provider with the Plan. 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 an eye examination. Our reviewer says that  Our physician reviewer found  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an eye examination have not been met.  
 
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 pay for an eye examination. Therefore, we decided that the Plan 
does not have to pay for an eye examination provided on May 30, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5212). 
 
You asked the Plan to pre-approve the dental service. You say that a new denture is medically necessary. 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 the date of service of December 29, 
2021. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the post cataract surgeries provided by an 
in-network provider on April 20, 2022, and the visual field exam provided by an in-network provider on May 
13, 2022.   
 
You asked the Plan to waive the copayment for the cataract surgeries, and the visual field exam. You say that 
you were told that the copayment would be lower. 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 $125 
copayment for in-network Medicare-covered surgical services in an ambulatory surgical center, and a $45 
copayment for in-network exams to diagnose and treat diseases and conditions of the eye provided by a 
specialist. 
 
You have been asked to pay a $159.08 copayment for both cataract surgeries ($53.03 + $106.05 = $159.08). 
These items/services fall within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. You have also been asked to pay a $43.81 
copayment for the visual field exam because the Plan is only holding you responsible for this amount which is 
less than the $45 copayment. This item/service falls within the vision 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 post cataract surgeries provided by an in-network provider on 
April 20, 2022, and the visual field exam provided by an in-network provider on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided 
on June 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to 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 October 25, 2022. 
Therefore, we decided that the Plan does not have to pay for a complete series of radiographic images (D0210) 
provided on June 29, 2023.