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

 
We decided that the Plan does not have to pay for the hearing aids (V5050) purchased on August 31, 2022, 
from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that the hearing aids you purchased from the OON 
provider are rechargeable and cost less. The Plan denied your request. The Plan says the claim does not meet 
criteria for approval because there are multiple contracted providers in your area accepting new patients, and no 
pre-authorization was obtained. The Plan also says the hearing aids were purchased from a non-contracted 
provider, and there is no evidence of a primary care physician referral. 
 
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 from an OON provider only when prior authorization has been obtained.  
 
We looked at 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. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5050) purchased on August 31, 2022, from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on July 18, 2022. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the provider depends on hospital staff 
to obtain authorization. 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 subsequent nursing 
care provided on July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0432, D4921 x4, D4000 x4) provided 
on August 22, 2022 
 
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 the dental 
services (D0432, D4921 x4, D4000 x4) provided on August 22, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on August 25, 
2022. 
 
You asked the Plan to pay for the resin-based composite (D2393). You say that you were unaware that you 
could not get the filling in your teeth. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the resin-based composite (D2393) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
resin-based composite (D2393) provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral examination (D0150), a panoramic 
radiographic image (D0330), and bitewings (D0274) provided on March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received a letter stating this would not be 
covered due to being seen at another office after this date of service. 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 4, 2022. The record 
shows this claim was received and paid first. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral examination (D0150), a panoramic radiographic image (D0330), and bitewings (D0274) 
provided on March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on May 09, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 lab testing provided on May 09, 2022, by an out-
of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ferumoxytol injection provided on May 
05, 2021, to May 10, 2021. 
 
You asked the Plan to waive the coinsurance for ferumoxytol injection. You say that you do not feel a year and 
a half later you should be paying more money. 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. 
 
You have been asked to pay 20% coinsurance for ferumoxytol injection. 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 coinsurance for 
ferumoxytol injection provided on May 05, 2021, to May 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on May 3, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would 
like help paying this bill because you are on social security and only get enough to survive. The Plan denied 
your request. The Plan says this service is not covered under your contract under any normal circumstances. 
 
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 May 3, 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 (A0998) provided on May 3, 2022.
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 July 
21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel this denial should be overturned 
because you only received the services ten days early. The Plan denied your request. The Plan says your 
benefits for the requested services had already been exhausted for the 6-month time period. 
 
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 benefits for the requested services were exhausted on date of service January 31, 2022, for the 6-
month time period. You would have been eligible for another oral exam and prophylaxis after July 30, 2022. 
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis 
provided on July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on July 27, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you are requesting a review of charges 
because you have previously ordered the same supplies and did 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 25% 
coinsurance for Medicare-covered durable medical equipment and supplies.  
 
You have been asked to pay a total coinsurance of $387.10, which is 25% of the allowed amount for DME 
($1,548.40 x 25% = $387.10). This item/service falls within the Medicare-covered durable medical equipment 
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. Therefore, we decided that the Plan does not have to waive the coinsurance for DME provided on July 
27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on September 01, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must get their care from network providers. Usually, the 
plan will not cover care from a provider who does not work with the plan (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 outpatient mental health provided on September 
01, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on August 10, 2022. 
 
You asked the Plan to pay for the bitewing x-rays. 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 bitewing 
x-rays (D0274) provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) provided on September 28, 2022. 
 
You asked the Plan to pay for the dental service. You say that you did not know that the evaluation was only 
covered once every 36 months. 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 9, 2021. Therefore, 
we decided that the Plan does not have to pay for an oral evaluation (D0150) provided on September 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code 72170. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 72170 is bundled into 
payment for code 72190. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72170 
is a column II code to column I code 72190. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 72170 billed for date of service June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on June 4, 2022, from an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you do not understand why the treating provider is 
not under contract with the Plan, because they provide good quality hearing aids. The Plan denied your request. 
The Plan says you did not contact the Plan's hearing vendor prior to receiving the hearing aids. The Plan also 
says you chose to go to an OON provider without approval from the Plan. 
 
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 when they are purchased from the Plan's approved hearing aid vendor. 
 
We looked at 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. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5298) purchased on June 4, 2022, from an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the neurostimulator analysis test provided 
on March 15, 2022. 
 
You asked the Plan to waive the copayment for the neurostimulator analysis test. You say that the test was 
always part of the office visit and should not have a separate copayment. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for diagnostic lab services and diagnostic procedures and tests. 
 
You have been asked to pay a $5 copayment for the neurostimulator analysis test. This item/service falls within 
the diagnostic lab services and diagnostic procedures and tests 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 neurostimulator analysis test provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
August 5, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient hospital services/Medicare-covered nonsurgical visit in an outpatient clinic.  
 
You have been asked to pay a $325 copayment for outpatient hospital services. However, you are only being 
asked to pay $171.49 which is less than the required amount. This item/service falls within the outpatient 
hospital services/Medicare-covered nonsurgical visit in an outpatient clinic 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 outpatient hospital services provided on August 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit and laboratory services 
provided on August 29, 2022. 
 
You asked the Plan to pay for a hospital outpatient clinic visit and laboratory services. You say that your are 
appealing with supporting 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 a hospital outpatient 
clinic visit and laboratory services provided on August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #13 (D2740) provided on August 10, 2022. 
 
You asked the Plan to pay for the crown. You say that you were already approved for the crown. The Plan 
denied your request. The Plan says that you are not eligible for coverage of this service. 
 
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 
your teeth or the structures directly supporting your 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 a crown on tooth #13 (D2740) 
provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on September 26, 
2022. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the records provided support medical 
necessity. 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 subsequent nursing 
care provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding a tooth to an existing partial denture for tooth #'s 20 
and 29 (D5650). 
 
You asked the Plan to pay for the adding a tooth to an existing partial denture for tooth #'s 20 and 29 (D5650). 
You say that the service was a much needed solution to correct a vital part of this critical procedures. You also 
say that the cost is devasting and will be a burden on your family financially. The Plan denied your request. 
The Plan says this service is not covered under the benefit package. 
 
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 adding a 
tooth to an existing partial denture for tooth #'s 20 and 29 (D5650).