Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
August 22, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. 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 $10 
copayment for outpatient diagnostic tests/labs.  
 
You have been asked to pay a $10 copayment for outpatient diagnostic tests. This item/service falls within the 
outpatient diagnostic tests/labs benefits 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 diagnostic tests provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7210) for tooth #24, #25, #26, #28, and #29 
provided on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were referred to the doctor by your dentist. 
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 extractions (D7210) for tooth #24, #25, #26, #28, and #29 provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an anterior resin-based composite of one surface (D2330) for 
teeth numbers 10 and 11, an anterior resin-based composite of two surfaces (D2331) for teeth numbers 7 and 9, 
and a posterior resin-based composite of one surface (D2391) for tooth  number 30 provided on October 10, 
2022. 
 
You asked the Plan to pay for an anterior resin-based composite of one surface (D2330) for teeth numbers 10 
and 11, an anterior resin-based composite of two surfaces (D2331) for teeth numbers 7 and 9, and a posterior 
resin-based composite of one surface (D2391). You say that one posterior filling was denied. You also asked 
why the plan does not cover anterior teeth. The Plan denied your request. The Plan says according to your EOC 
on pages 91 and 92, there is no coverage for these services. 
 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 an 
anterior resin-based composite of one surface (D2330) for teeth numbers 10 and 11, an anterior resin-based 
composite of two surfaces (D2331) for teeth numbers 7 and 9, and a posterior resin-based composite of one 
surface (D2391) for tooth  number 30 provided on October 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the durolane injection provided on June 
14, 2022. 
 
You asked the Plan to waive the coinsurance for the durolane injection. You say that the provider informed you 
that the injection was covered. 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 the durolane 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. The Medicare allowed amount for the injection is $2,129.04, and the 20% 
coinsurance is $425.81. Please note the Plan indicated the copayment for the procedure itself will be covered. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the durolane injection provided 
on June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shower chair (E0240) provided on June 2, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for the shower chair (E0240) provided on  
June 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on August 22, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for magnetic resonance imaging. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says the precertification entity was not contacted for 
precertification. 
 
 
 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 magnetic resonance imaging (MRI) provided on 
August 22, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wrist brace provided on August 12, 
2022. 
 
You asked the Plan to waive the coinsurance for the wrist brace. You say that you were informed the brace was 
covered without a 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 20% 
coinsurance for prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for the wrist brace. This item/service falls within the prosthetic 
devices and related 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. The Medicare allowed amount for the wrist brace is $222.62, and the 20% coinsurance 
applied is $44.52. Therefore, we decided that the Plan does not have to waive the coinsurance for the wrist 
brace provided on August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a complete lower denture (D5120) provided on 
September 19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the denture is a covered benefit, and you 
would like the Plan to correct the error. The Plan denied your request. The Plan says your annual dental benefit 
for the year 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 annual dental benefit was exhausted on date of service September 19, 2022. On September 15, 
2022, the Plan paid $54 for dental services. On September 19, 2022, the Plan paid $946 for the dental services. 
For the year of 2022 the Plan paid a total of $1,000 ($54 paid + $946 paid) for the yearly dental services. 
Therefore, we decided that the Plan does not have to pay more for a complete lower denture (D5120) provided 
on September 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bone density (DEXA) scan. 
 
You asked the Plan to waive the copayment for a DEXA scan. You say that you were unaware that there would 
be a copayment for this visit. 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 $45 
copayment for Physician/Practitioner services, including doctors office visits.  
 
You have been asked to pay the allowed amount of $39.76 which is less than the $45 copayment for a DEXA 
scan. This item/service falls within the Physician/Practitioner services, including doctors 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 bone density (DEXA) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on July 27, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 surgery/Medicare-covered surgery.  
 
You have been asked to pay a $325 copayment for an outpatient surgery. However, you are only being charged 
$144 which is less than the required amount. This item/service falls within the outpatient surgery/Medicare-
covered surgery 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 outpatient surgery 
provided on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 16, 
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 a limited 
oral evaluation (D0140) provided on August 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on September 14, 
2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that this should be covered. 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 
copayment for Ultrasound. 
 
You have been asked to pay a $100 copayment for ultrasound. This item/service falls within the Ultrasound 
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 ultrasound provided on 
September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 25, 2022 to June 1, 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 dental 
services provided on May 25, 2022 to June 1, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided on August 30, 2022. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for the dental services provided on August 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services (11042) provided on May 5, 2022. 
 
You asked the Plan to pay for procedure code 11042. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 15, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for procedure code 11042 have not been met. 
Therefore, we decided that the Plan does not have to pay for the debridement services (11042) provided on 
May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a preventive medicament application and protective 
restoration services (D2940, D1355) provided on June 8, 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 a 
preventive medicament application and protective restoration services (D2940, D1355) provided on June 8, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) and mask (E1399), purchased on June 30, 2022. 
 
You asked the Plan to pay for the CPAP device and mask. You say that the items are medically necessary. The 
Plan denied your request. The Plan says these items were purchased from a provider who is not under contract 
with the health plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure 
(CPAP) device (E0601) and mask (E1399), purchased on June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs provided on October 19, 
2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that this should be covered. 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 Part B drugs. 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. You have been asked to pay $586.40 which is 20% of the allowed amount for the injections. 
Therefore, we decided that the Plan does not have to waive the coinsurance for Part B drugs provided on 
October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit provided on July 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a physician visit. You say that the records attached support the services. The Plan 
denied your request. The Plan says there is no prior authorization on file for the services provided. 
 
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 a physician visit provided on July 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exam for physical therapy to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve an exam for physical therapy to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an exam for physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70551 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code 70551. 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 70551 is bundled into 
payment for code 70552. 
 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 70551 
is a column II code to column I code 70552. 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 70551 billed for date of service August 8, 2022.