Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on July 6, 2021. 
 
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physical therapy provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast biopsy provided on June 18, 2021. 
 
You asked the Plan to waive the copayment for a breast biopsy. You say that you already paid the copayment 
and do not understand 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 a $325 
copayment for outpatient surgery including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You received a breast biopsy at an outpatient hospital facility on June 18, 2021. A breast biopsy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $325 copayment.  
 
You have been asked to pay a $325 copayment for a breast biopsy. A breast biopsy 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 waive the copayment for a breast biopsy provided on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2752) for tooth #15. 
 
You asked the Plan to pre-approve the crown. You say that you would like to appeal this service. The Plan 
denied your request. The Plan says tooth #15 does not appear to have significant breakdown or demonstrate 
that there is pathologic destruction to the tooth by caries or trauma involving 4 or more surfaces and at least 
two cusps. 
 
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 the crown 
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 crown. Our reviewer says that given 
the severe damage to tooth #15 and the extent of the decay both toward the pulp of the tooth and extending to 
the bone on the mesial aspect, there would be no necessity found at this time for a crown, or for a foundation restoration which is dependent on receiving a crown. Our physician reviewer found the tooth has extensive 
mesial caries with the decay extending to and possibly beneath the bone. The tooth has no available mesial 
surface to allow for restoration. Our reviewer found that a tooth must be restorable in order to qualify for a 
crown restoration. The tooth may be salvageable if crown lengthening surgery is performed to expose more of 
the actual tooth structure, however this was not noted in the proposed treatment. Our physician reviewer also 
found that it is also noted that the tooth would likely require endodontic treatment as the decay appears to 
encroach on the pulp. 
 
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 crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2752) for tooth #15.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ten therapy sessions (97161, 97165, 
97530, 97110) provided from April 22, 2021, to May 20, 2021. 
 
You asked the Plan to waive the copayments for the therapy visits. You say that you did not know you would 
be responsible for any share of this cost and feel you should not have to pay these bills. The Plan denied your 
request. The Plan says these claims were processed correctly, and your cost-sharing responsibility was assessed 
in accordance with your contract. 
 
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 $35 
copayment for each therapy visit.  
 
 You have been asked to pay a $350 copayment for ten therapy visits ($35 x 10 visits = $350). 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 copayments for ten therapy sessions (97161, 97165, 97530, 97110) provided from 
April 22, 2021, to May 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the insertion of a multicomponent 
prosthesis provided on April 28, 2021. 
 
You asked the Plan to waive the coinsurance for the insertion of a multicomponent prosthesis. You say that you 
were not informed that you would owe such a high amount and thought that the provider was in-network. 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 40% 
coinsurance for out-of-network outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers.  
 
You received the insertion of a multicomponent prothesis at an out-of-network hospital facility on April 28, 
2021. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $22,057.55 and 40% of that is $8,823.02.  
 
You have been asked to pay the total coinsurance amount of $8,823.02 for the insertion of a multicomponent 
prosthesis. The insertion of a multicomponent prosthesis 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 waive the coinsurance for the insertion of a multicomponent prosthesis provided on April 28, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on April 7, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you thought your 
insurance would pay for these services. You also say that you are on a fixed income. The Plan denied your 
request. The Plan says you received these services from a provider who chose not to receive Medicare funds. 
The Plan also says that you did not contact the Plan prior to receiving these services, and you paid the opt out 
provider at the time of 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. 
 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 periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 
7, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tooth extraction (D7210) provided by a participating 
provider on June 23, 2021. 
 
You asked the Plan to pay for a tooth extraction. You say that you tripped on a sidewalk accidentally. You say 
that the Plan should pay for this. The Plan denied your request. The Plan says the dental services that were 
provided are 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 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 a tooth 
extraction (D7210) provided by a participating provider on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), simple extraction (D7140), and surgical extraction (D7210) provided on April 30, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the problem focused limited oral evaluation and extractions. You say that your primary dentist set up an appointment with the dentist you were treated by so you could have your teeth pulled immediately because of the infection. You also say that this treating provider was the first doctor you could get an emergency appointment with. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that it was confirmed with your primary dentist that the last time you were referred to the provider you were treated by was in 2019, and they no longer refer patients to this 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, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), simple extraction (D7140), and surgical extraction (D7210) provided on April 30, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visit you had with a sleep medicine 
specialist on May 12, 2021. 
 
You asked the Plan to waive the copayment for the visit with a sleep specialist. You say that these charges have 
been paid in full in the past. The Plan denied your request. The Plan says you were charged this copayment 
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 $30 
copayment for visits with a specialist.  
 
You have been asked to pay a $30 copayment for the visit with a sleep specialist. The visit with a sleep 
specialist falls within the visits with a specialist 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 visit you had with a sleep medicine specialist on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an application of desensitizing medicament (D9910) 
provided by a participating provider on June 23, 2021. 
 
You asked the Plan to pay for an application of desensitizing medicament. You say that this nerve causes a lot 
of pain. You say that you would like to lessen that pain. The Plan denied your request. The Plan says this 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 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 an 
application of desensitizing medicament (D9910) provided by a participating provider on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to fully pay for the intraoral x-ray provided on May 13, 2021 and the 
complete upper denture provided on June 9, 2021. 
 
You asked the Plan to fully pay for the intraoral x-ray and complete upper denture. You say that you were told 
prior to the appointment that the doctor is in-network. You say that social security is your only source of 
income and you are requesting reimbursement for the initial visit. The Plan denied your request. The Plan says 
the claim reprocessed toward your in-network benefits as a one-time exception. 
  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 Plan paid $1,150 toward the cost of 
the comprehensive oral evaluation and complete upper denture, which exhausted your benefit. Therefore, we 
decided that the Plan does not have to fully pay for the intraoral x-ray provided on May 13, 2021 and the 
complete upper denture provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that 
includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water 
and/or phone bill payments (debit card), home assistance services (repairs). 
 
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes 
transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or 
phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan 
says the certification dated October 14, 2021, documented that the enrollee has none of the qualifying 
diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for 
adverse health outcomes. 
 The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you 
must have one or more comorbid and medically complex chronic conditions that are life-threatening or 
significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization 
or other adverse health outcomes; and must require intensive care coordination.  
 
We looked at the file and Plan?s rules. The file shows that your medical conditions are not eligible medical 
conditions for coverage under the Plan?s benefit. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, 
an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home 
assistance services (repairs).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit to a specialist (99213) 
rendered on August 30, 2021. 
 
You asked the Plan to waive the copayment for an office visit to a specialist. You say that neither your 
preoperative visit nor your first three postoperative visits required a copayment. You also say that when you 
returned for your final six month postoperative visit, you were told to pay a copayment. You also say that all of 
the visits and the surgery itself represent a package deal that covers all aspects of the surgery, including all 
follow up appointments. The Plan denied your request. The Plan says you were 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 $45 
copayment for each office visit to a specialist.   
You have been asked to pay a $45 copayment for an office visit to a specialist. Please note that the contract 
does not indicate that cost sharing would be waived for follow up visits six months after a surgery. 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 office visit to a specialist (99213) rendered on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 28, 2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you received a bill for $40 and 
want to know whether you owe $10 or $40. 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 $40 
copayment for specialist services.  
 
You have been asked to pay $10, which is less than the $40 copayment for a specialist visit. A specialist visit 
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 copayment for a specialist visit provided on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a periodic oral evaluation (D0120), teeth 
extractions (D7140), an intraoral - periapical first radiographic image (D0220) and an intraoral periapical 
additional radiographic image (D0230) provided on May 27, 2021 by a non-participating provider. 
 
You asked the Plan to reimburse you for dental services. You say that you had no choice but to see this dentist. 
You also say your teeth were bad and you were in a lot of pain. The dentist you chose was the only dentist you 
could see during Covid-19. Your top denture was 20 years old, so it needed to be replaced. You are requesting 
reimbursement of the allowable amount. The Plan denied your request. The Plan says services performed by an 
OON provider are not covered because your healthcare Plan does not have OON benefits. 
 
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 reimburse you for 
a periodic oral evaluation (D0120), teeth extractions (D7140), an intraoral - periapical first radiographic image 
(D0220) and an intraoral periapical additional radiographic image (D0230) provided on May 27, 2021 by a 
non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical need for this power wheelchair with a single power option. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 there is no 
documentation that the enrollee would be able to safely operate this power wheelchair. Based on the medical 
records provided there is no documentation that the enrollee meets Medicare criteria for power tilt/recline. 
Records do not document she is at high risk for skin breakdown, requires intermittent catherization or has 
spasticity. The seat elevator is statutorily non-covered by Medicare as it is not primarily medical in 
nature. Although the enrollee does not meet criteria for a group 3 power wheelchair with a single power option 
she does appear to meet criterial for a group 3 power wheelchair with no power option. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with accessories for the enrollee.