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

 
We decided that the Plan does not have to waive the copayment for an eye exam (92004) provided on May 3, 
2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the services should be covered as 
you disagree with the denial. 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 $50 
copayment for Vision care.  
 
 
  You have been asked to pay a $50 copayment for the eye exam. 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 an eye exam (92004) provided 
on May 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on June 08, 2022, to 
June 27, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 each day in a hospital for the first five days; you pay $0 for each day after day 5 for each 
inpatient stay. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of 
inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a 
doctors order. The day before you are discharged is your last inpatient day. 5 x $325 = $1,625. Therefore, 
results in the total cost sharing amount of $1,625.  
 
 You have been asked to pay a $325 copayment each day for inpatient hospital 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 
inpatient hospital stay on June 08, 2022, to June 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation (97032) or waive the copayment for a 
chiropractic manipulative treatment (98941) provided from July 25, 2022, to August 15, 2022. 
   
You asked the Plan to pay for electrical stimulation (97032) and to waive the copayment for a chiropractic 
manipulative treatment (98941). You say that chiropractic manipulation once or twice a month permits some 
normalcy to maintaining moving at your age, even with a cane. The Plan denied your request. The Plan says 
your coverage does not provider for this physical therapy service when performed by this type of provider. The 
Plan also says that no payment can be made. The Plan also says that this cost sharing was charged correctly for 
a chiropractic manipulative treatment (98941). 
 
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 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 they only cover 
manual manipulation of the spine to correct subluxation. Electrical stimulation (97032) is excluded from this 
benefit. You contract with the Plan also clearly says that you must pay a $20 copayment per Medicare-covered 
visit for chiropractic services. 
 
The records show that electrical stimulation (97032) is not manual manipulation of the spine.  
 
You have been asked to pay a $20 copayment per Medicare-covered visit for a chiropractic manipulative 
treatment for 2 visits, which is a total of $40 ($20 x 2 = $40). This item/service falls within the chiropractic 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. 
 
Therefore, we decided that the Plan does not have to pay for electrical stimulation (97032) or waive the 
copayment for a chiropractic manipulative treatment (98941) provided from July 25, 2022, to August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on January 05, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for podiatry services. 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 podiatry services provided on January 05, 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 eye injections provided on March 16, 
2022, and May 19, 2022. 
 
You asked the Plan to waive the coinsurance for eye injections. You say that you shouldn't have this 
coinsurance. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B drugs. The allowed amount of this drug or item is $2,046.16, resulting in a 
coinsurance amount of $366.30 ($2,046.16 x 20% = $366.30) which is less than the full 20%. The allowed 
amount of this drug or item is $1,936.41, resulting in a coinsurance amount of $365.68 ($1,936.41 x 20% = 
$365.68) which is less than the full 20%. $366.30 + $365.68 = $731.98 total. 
 
You have been asked to pay a total $731.98 coinsurance for eye injections. This item/service falls within the 
Medicare Part B 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 eye injections provided on March 16, 2022, 
and May 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 25, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on September 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like you were given misleading 
information. 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 prophylaxis. Therefore, 
we decided that the Plan does not have to pay for prophylaxis (D1110) provided by on September 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) and a retainer crown (D6750) for tooth 
#28, #29, and #30. 
 
You asked the Plan to pre-approve the dental services. You say that the provider told you that the dental 
services would be covered. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because pontics and retainer crowns are not covered by the Plan. 
 
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 pre-approve a 
pontic (D6240) and a retainer crown (D6750) for tooth #28, #29, and #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392) 
Tooth #15 provided on August 11, 2022. 
 
You asked the Plan to pay for dental services. You say that you should not have to pay for the service provided. 
The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Resin-based composite - two 
surfaces, posterior is not covered under the Plans dental benefits. Refer to the medical benefits chart and the 
dental fee schedule for a complete description of coverage. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested resin-based composite - 
two surfaces, posterior (D2392) Tooth #15 is not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392) Tooth 
#15 provided on August 11, 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 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel you should not be liable. 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 5, 2022. Therefore, 
we decided that the Plan does not have to pay for an incisional biopsy of oral tissue-soft (D7286) provided on 
April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on August 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to have another oral examination. 
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 15, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on July 27, 2022. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused (D0140), and intraoral - periapical 
first radiographic image (D0220). You say that you are asking the Plan to readjust the claim amount for this 
dental service based on in-network coverage. The Plan denied your request. The Plan says these services are 
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 a limited 
oral evaluation - problem focused (D0140), and intraoral - periapical first radiographic image (D0220) 
provided on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and rooting (D4921) provided by a 
participating provider on July 21, 2022. 
 
You asked the Plan to pay for periodontal scaling and rooting. You say that you do not know why this is not 
covered. The Plan denied your request. The Plan says the rendered service has been processed correctly. 
 
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 
periodontal scaling and rooting (D4921) provided by a participating provider on July 21, 2022.  
 
The fluoride varnish (D1206) provided was not denied, and was paid by the Plan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for a panoramic radiographic 
image (D0330) provided on August 17, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for a panoramic radiographic image. You say that 
you do not agree with these charges. 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 $100 
deductible for Dental Services/Class 2 Basic Services first and a 50% coinsurance for Dental Services/Class 2 
Basic Services.  
 
You have been asked to pay a $100 deductible and a 50% coinsurance of the allowed amount for a panoramic 
radiographic image. The total allowed amount is $3.00. The 50% coinsurance being asked to pay is $1.50 
($3.00 x 50% = $1.50). The total amount you are being asked to pay is $101.50 ($100 deductible + $1.50 
coinsurance = $101.50). This item/service falls within the Dental Services/Class 2 Basic Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the deductible and coinsurance for a panoramic radiographic 
image (D0330) provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) Tooth #20, core buildup, 
including any pins when required (D2950) Tooth #20, unspecified periodontal procedure, by report (D4999), 
custom fabricated abutment includes placement (D6057) Tooth #19, and abutment supported porcelain/ceramic 
crown (D6058) Tooth #19 provided on October 20, 2022. 
 
You asked the Plan to pay for dental services. You say that you were told by the providers office that the 
services would be covered. The Plan denied your request. The Plan says this service is not covered under your 
Plan. 
  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. Crown - porcelain/ceramic 
(D2740), core buildup, including any pins when required (D2950), unspecified periodontal procedure, by report 
(D4999), custom fabricated abutment includes placement (D6057), and abutment supported porcelain/ceramic 
crown (D6058) are not covered under the Plans dental benefits. 
 
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 crown - 
porcelain/ceramic (D2740) Tooth #20, core buildup, including any pins when required (D2950) Tooth #20, 
unspecified periodontal procedure, by report (D4999), custom fabricated abutment includes placement (D6057) 
Tooth #19, and abutment supported porcelain/ceramic crown (D6058) Tooth #19 provided on October 20, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), bitewing x-rays (D0270, D0274), a 
periodic oral evaluation (D0120), and a periapical x-ray (D0220) provided on September 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know that the office did not take 
insurance. 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 prophylaxis (D1110), bitewing x-rays (D0270, D0274), a periodic oral evaluation (D0120), and a 
periapical x-ray (D0220) provided on September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and 
unspecified preventive procedure (D1999) provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says these services are not covered by the Plan's 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 
topical application of fluoride varnish (D1206) and unspecified preventive procedure (D1999) provided on 
June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on July 21, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the Plan pre-approved the dental procedures 
when you were at the providers office. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the periodontal maintenance is not covered by the Plan. Also, the Plan 
confirmed that the provider was told the enrollee's policy does not have out-of-network 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 
periodontal maintenance (D4910) provided on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical radiographic image (D0220) and the sales tax 
(D9985) provided on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were on vacation, and it was an emergency 
to get the dental services done. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the periapical radiographic image and the sales tax are not covered by the Plan. 
 
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 
periapical radiographic image (D0220) and the sales tax (D9985) provided on August 8, 2022.