Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
September 14, 2021, to September 26, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were not aware that 
inpatient coverage had such a high copayment. You also say that you are on a fixed income, and this is out of 
your price range. 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 $350 
copayment per day for days 1-5 for an inpatient hospital stay. The contract says there is a $0 copayment for 
additional days after day 5. The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $1,750, which is a $350 copayment per day for the first five days of an inpatient hospital stay ($350 
copayment x 5 days = $1,750). There is no charge after day 5. An inpatient hospital stay 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 inpatient 
hospital stay provided from September 14, 2021, to September 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray 
(D0330), and incisional biopsy of oral tissue (D7286) provided on November 23, 2021 by a Medicare opt out 
provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, panoramic x-ray, and incisional biopsy of 
oral tissue. You say that you believe these services should be covered under the non-routine dental care listed 
in your policy. The Plan denied your request. The Plan says the treating provider has been opted out of 
Medicare effective October 4, 2016. The Plan also says that this claim 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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), and 
incisional biopsy of oral tissue (D7286) provided on November 23, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2751) for teeth # 3, 4, 5, 11, 12 and 13. 
 
You asked the Plan to pre-approve the dental services. You say that you have an infection in the area. You say 
that it is worsening. You also say that these services are medically necessary. The Plan denied your request. 
The Plan says the provided documentation does not clearly support that the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of crowns have been met. Specifically, 
the file does not include sufficient documentation indicating that the services are medically necessary. 
Therefore, we decided that the Plan does not have to pre-approve crowns (D2751) for teeth # 3, 4, 5, 11, 12 and 13.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for Ophthalmology services on 
October 13, 2021. 
 
You asked the Plan to waive the deductible and coinsurance for Ophthalmology services. You say that you do 
not have money for this. The Plan denied your request. The Plan says the cost share applied was correct. 
 
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, a $203 deductible for Ophthalmology services. At the time this claim was processed, $147.92 of 
the $203 deductible had been met, resulting in a deductible amount of $55.08. With the addition of the 20% 
coinsurance your total cost-sharing amount is $149.22. 
 
 You have been asked to pay 20% coinsurance, a $203 deductible for Ophthalmology services. Ophthalmology 
services falls within the Physician/Practitioner services, including doctor's office visits 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 Ophthalmology services on October 13, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), deep sedation/general 
anesthesia, first 15 minutes (D9222), deep sedation/general anesthesia, each subsequent 15-minute increment 
(D9223), a therapeutic parenteral drug (D9610) and three teeth extractions (D7210) provided on April 20, 
2021, to April 28, 2021, by a non-participating provider. 
 
You asked the Plan to pay for dental services. You say that the dental services were medically necessary 
because of a cancerous lesion on your gums. You also say you searched all over the area for a dentist 
who accepted Medicare but was unsuccessful. The Plan denied your request. The Plan says you got the service 
from a provider who chose not to receive Medicare funds. This means they're on the Medicare opt-out list. For 
this benefit, you can see any licensed provider, in the U.S., that isn't on the opt-out list. 
 
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 services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. We have confirmed that the provider opted out of Medicare on October 
18, 2016. This means that the provider was opted out of Medicare for the date of service at issue. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation (D0140), deep sedation/general 
anesthesia, first 15 minutes (D9222), deep sedation/general anesthesia, each subsequent 15-minute increment 
(D9223), a therapeutic parenteral drug (D9610) and three teeth extractions (D7210) provided on April 20, 
2021, to April 28, 2021, by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry (83879) provided on June 9, 2021. 
 
You asked the Plan to pay for the mass spectrometry. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says a complete description of the not elsewhere 
specified code was not included. 
 
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 the mass spectrometry have not been met. Specifically, the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the mass spectrometry (83879) provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for An Office Visit provided on November 3, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for An Office Visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
office visit. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for An Office Visit provided on November 3, 2021, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of ultrasound, limited, joint or other nonvascular 
extremity structures (76882-26) provided on October 28, 2021. 
 
You asked the Plan to pay for the ultrasounds. You say that these services were necessary for the enrollee's 
medical condition and were billed appropriately. The Plan denied your request. The Plan says a National 
Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 93970 and 76882. 
This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. This service was not billed as 
required by Medicare coding regulations. 
 
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 76882 
is a column II code to column I code 93970. 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 two units of ultrasound, limited, joint or other nonvascular 
extremity structures (76882-26) provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for travel and lodging expenses provided from 
November 15, 2021, through December 23, 2021. 
 
 
 
 You asked the Plan to reimburse you for travel and lodging expenses. The Plan denied your request. The Plan 
says the record sent by your provider indicates there was cancer in your native lungs, which has spread and the 
reason for your continued stay near your transplant facility is for cancer treatment. Your Evidence of Coverage 
does not provide supplemental benefit coverage for cancer treatment 
 
The Plan contract says if our in-network transplant services are outside the community pattern of care, you may 
choose to go locally as long as the local transplant providers are willing to accept the Original Medicare rate. If 
the Plan provides transplant services at a location outside the pattern of care for transplants in your community 
and you choose to obtain transplants at this distant location, we will arrange or pay for appropriate lodging and 
transportation costs for you and a companion. If you are sent outside of your community for a transplant, we 
will arrange or pay for appropriate lodging and transportation costs for you and a companion. 
 
We looked at the file and the Plans rules. The file shows that the record sent by your provider indicates there 
was cancer in your native lungs, which has spread and the reason for your continued stay near your transplant 
facility is for cancer treatment. Your Evidence of Coverage does not provide supplemental benefit coverage for 
cancer treatment. Based on this information, we decided that the Plans rules for coverage of travel and lodging 
expenses have not been met. Therefore, we decided that the Plan does not have to reimburse you for travel and 
lodging expenses provided from November 15, 2021, through December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the resin-based composites - two 
surfaces, anterior (D2331) provided December 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the fillings. You say that the fillings were medically 
necessary, and it was practical to have the fillings all done on the same date of service. The Plan denied your 
request. The Plan says two fillings were covered according to your OON benefits, and the third filling exceeds 
the frequency limit for this service. 
 
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. The Plan covers two fillings 
with 55% coinsurance when provided OON. 
 
We looked at the file and Medicare rules. In this case the Plan provided documentation showing you have been 
asked to pay 55% of the allowed amount for two of the fillings. Additionally, you may be responsible for the 
difference between the allowed amount and the total cost billed by the OON provider. The third filling is not 
covered because you have exceeded the frequency limit for the service. Therefore, we decided that the Plan 
does not have to provide additional payment for the resin-based composites - two surfaces, anterior (D2331) 
provided December 8, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210). 
 
You asked the Plan to pre-approve surgical tooth extractions. You say that the extractions are absolutely 
necessary. The Plan denied your request. The Plan says you have exceeded the frequency limit for the 
extractions. 
 
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 Plan covers surgical tooth 
extractions three times per year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that three tooth 
extractions were previously covered. Based on this information, we decided that the Plan's frequency limit for 
coverage of surgical tooth extractions will be exceeded with the requested service. Therefore, we decided that 
the Plan does not have to pre-approve extractions, erupted tooth requiring removal of bone and/or sectioning of 
tooth and including elevation of mucoperiosteal flap if indicated (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341). 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that you recommend the 
enrollee has the periodontal scaling and root planing completed. The Plan denied your request. The Plan says 
the enrollee will exceed the frequency limit for this service. 
 
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 Plan covers periodontal 
scaling and root planing once per quadrant every three calendar years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal scaling 
and root planing was previously covered for all four quadrants on August 19, 2021. Based on this information, 
we decided that the Plan's frequency limit for coverage of periodontal scaling and root planing will be exceeded 
with the requested service. Therefore, we decided that the Plan does not have to pre-approve periodontal 
scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D6010, D6056, D6056) for teeth #2-15. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says implants are covered only when medically necessary and when a single tooth is missing 
in an arch (excluding third molars) or as support for an implant supported full denture when there is inadequate 
bone to support a denture or history of a failed attempt at retaining a denture (maximum allowance is four 
implants on the maxillary arch and two implants on the mandibular arch). 
 
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 Plan covers the services 
when the services are medically necessary and reasonable.  
 
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 pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found this service is 
beyond the scope of the plan. The plan covers an implant for a single missing tooth in an arch or as support for 
an implant supported full denture (4 implants). The documentation indicates that the requested service is for 15 
individual implant supported crowns on teeth 2-15. The requested service does not meet the criteria for 
coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental services (D6010, D6056, D6056) for teeth #2-15.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
(A0998) provided on November 18, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment without transport. You say that you would 
like reconsideration because these services were not provided and you did not request them. The Plan denied 
your request. The Plan says if you refuse transport when an ambulance is dispatched, you will be responsible 
for the full cost of the service. 
 
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 November 18, 2021. 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 without 
transport (A0998) provided on November 18, 2021.  
 
Your complaint about the services not being rendered is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay the coinsurance for the outpatient surgery provided from 
November 29, 2021, to November 30, 2021. 
 
You asked the Plan to pay the coinsurance for the outpatient surgery. You say that you believe the surgery 
should have been fully covered and not denied. The Plan denied your request. The Plan says the service was 
covered, and the proper coinsurance was applied. 
  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 $1,600 
for Combined maximum out-of-pocket (MOOP) amount for in and out-of-network services and a 10% 
coinsurance for each Medicare-covered outpatient hospital facility visit. Prior to the date of service, the total 
amount paid towards the yearly MOOP was $828.41 leaving a balance of $771.59 ($1,600 yearly MOOP - 
$828.41 paid towards MOOP). The total amount allowed for the surgery was $12,340.66 and a 10% 
coinsurance would have been $1,234.07 ($12,340.66 total amount allowed x 10% coinsurance). Since $771.59 
was left of the yearly MOOP that was charged as the coinsurance. 
 
You have been asked to pay a $771.59 coinsurance for the outpatient surgery. The outpatient surgery falls 
within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 the coinsurance for the outpatient surgery 
provided from November 29, 2021, to November 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on November 30, 2021, 
and January 4, 2022, by an OON provider. 
 
You asked the Plan to pay for the outpatient mental health. You say that you have seen this provider for years 
and do not want to change providers. The Plan denied your request. The Plan says the services were provided 
out-of-network and were not approved in advance. 
 
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 November 
30, 2021, and January 4, 2022, by an OON provider.