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

We decided that the Plan does not have to waive the coinsurance for dialysis provided on January 1, 2020.
You asked the Plan to waive the coinsurance for dialysis. You say that you disagree with the additional
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being
charged the correct amount.
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 services to treat kidney disease.
You received dialysis on January 1, 2020. The allowed amount is $288.51 and 20% of that is $57.70.
You have been asked to pay the total coinsurance amount of $57.70 for dialysis. Dialysis falls within the
services to treat kidney disease 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 coinsurance for
dialysis provided on January 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up for teeth # 7 and 29, and a porcelain
crown (D2740) for tooth # 7.
You asked the Plan to pre-approve the core build up, and crown for tooth # 7. You say that these services were
recommended by your dentist as they are necessary. You also say that due to the severe pain that you are in you
are hardly able to eat. The Plan denied your request. The Plan says core build up and porcelain crowns are not
listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested core build up and
porcelain crown are not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pre-approve core build up for teeth # 7 and 29, and a porcelain crown (D2740) for tooth # 7.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a Positron Emission Tomography (PET) scan (78816) performed October 14, 2019.
You asked the Plan to pay for the PET scan. You say that the PET scan was medically necessary. The Plan denied your request. The Plan says that coverage criteria was not met.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 PET scan. Our reviewer says that rules for coverage have been met. Our physician reviewer found the patient has a positive cervical node and question of additional cervical nodes on PET performed in October 2019. Per the NCCN Guidelines Version 1.2020 Cutaneous Melanoma PET is indicated for the follow-up of equivocal lymph nodes and should be reassessed with a short term follow-up PET scan. 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 PET scan have been met. Therefore, we decided that the Plan has to pay for a Positron Emission Tomography (PET) scan (78816) performed October 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on February 3,
2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that this was supposed to be just a
screening colonoscopy, which you have every five years. The Plan denied your request. The Plan says you
have been charged the correct cost sharing amount.
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 for outpatient procedures and services, including but not limited to diagnostic and
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical
center.
You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
center" benefit category. The medical record shows the colonoscopy was performed due to chronic diarrhea,
which makes the colonoscopy diagnostic as nature.
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 colonoscopy provided on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 15,
2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0480 (1 Unit) remains not
supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of
the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing
services provided to the enrollee on July 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on February 27,
2020 and March 5, 2020.
You asked the Plan to waive the coinsurance for the Part B drug. You say that you paid your copayments for
the treatments. The Plan denied your request. The Plan says the coinsurance applied 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 covered Part B drugs and other Medicare covered items.
You have been asked to pay a total of $42.45 for the Part B drug.
The Part B drug 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 coinsurance for the Part B drug provided on February 27, 2020 and March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wellness visit received on October 15, 2019.
You asked the Plan to pay for the wellness visit. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12
months.
We looked at the file and Medicare rules. Review of the file shows that you had an annual wellness visit on
October 15, 2019. You previously had an annual wellness visit on August 23, 2019. The visit on October 15,
2019 was less than 12 months from your prior annual wellness visit. Based on this information, we decided that
Medicare rules for coverage of the wellness visit have not been met. Therefore, we decided that the Plan does
not have to pay for the wellness visit received on October 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on June 17, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you did not receive any services and
just accompanied your daughter for bug bites. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct amount.
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.
The medical records show that you had an ER visit on June 17, 2019. Therefore, you are responsible to pay the
$110 copayment.
You have been asked to pay a $110 copayment for an ER visit. An ER visit 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 an ER visit provided on June 17,
2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laser assisted cataract surgery provided on September 12,
2019 and October 11, 2019.
You asked the Plan to pay for the laser assisted cataract surgery. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered
benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a
conventional IOL.
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatismcorrecting
feature of an IOL. The add-ons for cataract surgery like the astigmatic package is not a covered
benefit. You are required to pay this amount on top of the copayment requirement for these services. Therefore,
we decided that the Plan does not have to pay for the laser assisted cataract surgery provided on September 12,
2019 and October 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient procedures provided on
January 22, 2020.
You asked the Plan to waive the copayment for the outpatient procedures. You say that you scheduled a
screening colonoscopy. You say that you don't believe the copayment should apply. The Plan denied your
request. The Plan says the copayment applied 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 $225 for
each in-network, Medicare-covered ambulatory surgical center visit.
You have been asked to pay a $225 copayment for the outpatient procedures. The outpatient procedures fall
within the "Outpatient surgery including services provided at hospital outpatient facilities and ambulatory
surgical centers" benefit category. The colonoscopy and anus procedure are considered surgical procedures.
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 outpatient procedures provided on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to partially pay for the periodontal maintenance provided on September 12, 2019.
You asked the Plan to partially pay for the periodontal maintenance. You say that you are eligible for one dental cleaning visit per year. The Plan denied your request. The Plan says this service is not a benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 partially pay for the periodontal maintenance provided on September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (code D0150) provided on
September 3, 2019.
You asked the Plan to pay for the comprehensive oral evaluation (code D0150). You say that you were seen by
the Dental office and under the impression it was in-network. The Plan denied your request. The Plan
says the provider that rendered the service is not a network provider. The Plan also says that services provided
by an out-of-network dentist are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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
covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for
the comprehensive oral evaluation (code D0150) provided on September 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on October 8, 2019.
You asked the Plan to pay for the dental services. You say that you found the provider on the Dental's list of participating providers. The Plan denied your request. The Plan says that the provider in this case is not a participating providerl. The Plan also says that dental services received out of network are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance and topical application of
fluoride varnish provided on August 27, 2019.
You asked the Plan to pay for the periodontal maintenance and topical application of fluoride varnish. You say
that it was recommended for you to have a prophylactic dental cleaning/exam prior to starting your oral
chemotherapy regimen. The Plan denied your request. The Plan says any combination of prophylaxes, full
mouth debridement and periodontal maintenance procedures are payable twice per calendar year. The Plan also
says that fluoride treatments are not benefits of the Dental Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, fluoride treatments are not among
those covered under this benefit. Prophylaxes (cleanings) are payable twice per calendar year. The record
shows that you received periodontal maintenance procedures on February 27, 2019 and June 4, 2019 and your
cleanings benefit is now exhausted. Therefore, we decided that the Plan does not have to pay for the
periodontal maintenance and topical application of fluoride varnish provided on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, and prophylaxis provided on September 24, 2019.
You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, bitewings, and prophylaxis. You say that the enrollee believed that this provider was in-network with the Plan because they took the enrollee's identification card when he went in for his first appointment. The Plan denied your request. The Plan says the services were received from an out-of-network provider. The Plan also says that neither the provider nor the enrollee confirmed the provider's network status prior to the services being rendered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, and prophylaxis provided on September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain - minor
procedure and first intraoral periapical x-ray provided on September 11, 2019.
You asked the Plan to pay for the palliative treatment of dental pain and x-ray. You say that the service was for
a broken crown. You also say that the coverage guide says that the Dental covers crowns. The Plan denied
your request. The Plan says these procedures are not covered benefits under the Dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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 the
palliative (emergency) treatment of dental pain - minor procedure and first intraoral periapical x-ray provided
on September 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on March 21, 2019.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that when you signed up for the dental PPO, you checked the Dental directory and found this provider listed. The Plan denied your request. The Plan says this provider is non-contracted with your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on March 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the dental cleaning
(D1110), or the bitewing x-rays (D0274) provided on September 16, 2019.
You asked the Plan to pay for the periodic oral evaluation (D0120), the dental cleaning (D1110), and the
bitewing x-rays (D0274). You say that you should have been told by the office that the dentist was not in the
network. The Plan denied your request. The Plan says services done by an out-of-network dentist are not
covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network services are not among
those covered under this benefit. The record shows your dentist is an out-of-network provider. Therefore, we
decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the dental cleaning
(D1110), or the bitewing x-rays (D0274) provided on September 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274), and the full mouth debridement
to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided on September
30, 2019.
You asked the Plan to pay for the dental services. You say that you moved to the area in May 2019. You say
that you were referred to this dental office. You say that you presented both your Dental and Medicare
cards. You also say that you feel the dentist has the responsibility to clarify coverage to you. The Plan denied
your request. The Plan says they confirmed with the dental office that the provider in this case has opted out of
Medicare. The Plan also says they are unable to pay for services received from a provider that has opted out of
Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The provider in this case has opted out of the Medicare program. The file shows that the provider entered into a
private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the
bitewing x-rays (D0274), and the full mouth debridement to enable a comprehensive oral evaluation and
diagnosis on a subsequent visit (D4355) provided on September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the prophylaxis (D1110) provided on October 23, 2019.
You asked the Plan to pay for the dental services. You say that you called the provider's office prior to your appointment to verify that they accept your plan. You say that the provider's office advised that they do accept your plan. You also say that you should not have to pay for the services because you were given the wrong information by the provider. The Plan denied your request. The Plan says benefits are provided under your dental plan only for services provided by a network dentist who participates in the Dental PPO network. The Plan also says that the provider in this case is not a network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the services you received are listed as covered services, they are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the prophylaxis (D1110) provided on October 23, 2019.