Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the wearable defibrillator provided on 
September 4, 2022, and October 4, 2022. 
 
You asked the Plan to waive the cost sharing for the wearable defibrillator. You say that you feel that you 
should not be responsible for the cost sharing amount. 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 high-cost durable medical equipment. 
 
You have been asked to pay a cost share of $1109.14 for the wearable defibrillator ($2772.86 allowed amount 
x .20 = $554.57) ($554.57 x 2 dates of service = $1109.14). This item/service falls within the durable medical 
equipment (DME) 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. Therefore, we decided that the Plan does not have to waive the cost sharing 
for the wearable defibrillator provided on September 4, 2022, and October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 23, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete dentures (D5130, D5140) provided on October 24, 
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 complete 
dentures (D5130, D5140) provided on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the eyewear provided on November
19, 2021.
You asked the Plan to provide additional payment for the eyewear. You say that you would like reconsideration
of your member responsibility. The Plan denied your request. The Plan says that you are responsible for any
amount of the $100 retail price.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan says that there is a $100 (combined in and out-of-network) benefit toward the purchase and
fitting of eyeglasses and pair of lenses or contact lenses.
We looked at the file and the Plan's rules. The total cost charged for the eyewear was $335. The Plan then paid
$100 leaving $235. A 20% discount ($47) was then applied leaving a balance of $188 that you are responsible
for. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met.
Therefore, we decided that the Plan does not have to provide additional payment for the eyewear provided on
November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and ultrasound provided 
September 8, 2022. 
 
You asked the Plan to waive the copayment for an office visit and ultrasound. You say that you would like to 
be reimbursed for any amount you are able to receive. 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 $60 
copayment for Medicare-covered x-ray and ultrasounds and a $20 copayment for each Medicare-covered eye 
exam to diagnose and treat diseases and conditions of the eye.  
 
  You have been asked to pay a total copayment of $57.40 for an office visit and ultrasound. This total includes a 
$20 copayment for an office visit, and a $12.40 copayment for an ultrasound, which is less than the standard 
$60 copayment. The ultrasound falls within the outpatient diagnostic tests benefit category. The office visit 
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 office 
visit and ultrasound provided September 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
September 17, 2022, to September 18, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you paid a copayment 
while you were at the facility. You do not understand why you are being billed again. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
emergency 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 emergency room services 
provided on September 17, 2022, to September 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on July 10, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service is not payable as it was rendered 
by an ineligible provider.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on  
July 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames and lenses purchased on September 9, 2022. 
 
  You asked the Plan to pay for frames and lenses. You say that you found two pairs of glasses for around $100. 
The Plan denied your request. The Plan says they issued payment for the first pair of eyewear received from the 
provider on date of service September 9, 2022. The Plan also says that therefore, the second pair of eyewear 
denied correctly as a duplicate service - exceeds frequency limit for this benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of standard lenses and frames every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one pair of standard lenses and 
frames every two years. The record shows this benefit was exhausted on September 9, 2022. Based on this 
information, we decided that the Plan's rules for coverage of frames and lenses have not been met. Therefore, 
we decided that the Plan does not have to pay for frames and lenses purchased on September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7950) provided on 
November 4, 2022. 
 
You asked the Plan to pay for the removal of residual tooth roots. You say that if you would have known it 
would cost this much, you would not have had the procedure done. The Plan denied your request. The Plan 
says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 
removal of residual tooth roots (D7950) provided on November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an office visit and knee x-rays provided on 
June 20, 2022. 
 
You asked the Plan to reduce the copayment for the office visit and knee x-rays. You say that your copayment 
should only be $40 for the office 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 $40 
copayment for specialist office visits and a $50 copayment for x-rays in a providers office.  
 
 
  You have been asked to pay a $40 copayment for the office visit. This item/service falls within the specialist 
office visits benefit category. You have also been asked to pay a $50 copayment for the knee x-rays. This 
item/service falls within the x-rays in a providers office 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 reduce 
the copayment for an office visit and knee x-rays provided on June 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on August 06, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
August 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of fluoride (D1206) and the periodontal 
maintenance (D4910) provided on November 17, 2022. 
  You asked the Plan to pay for the dental services. You say that the dental services should be covered, and you 
have not hit your annual dental maximum. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because the application of fluoride and the periodontal maintenance 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 
application of fluoride (D1206) and the periodontal maintenance (D4910) provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on July 12, 2022. 
 
You asked the Plan to pay for physician services. You say that you are appealing based on medical necessity 
and the records submitted. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physician services 
provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral radiographic 
image (D0220), and core buildup (D2950) for tooth #18 provided by an out-of-network provider on November 
28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services should be covered. 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 a limited oral evaluation (D0140), intraoral radiographic image (D0220), and core buildup (D2950) 
for tooth #18 provided by an out-of-network provider on November 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-rays provided on September 22, 2022. 
 
You asked the Plan to pay for the chest x-rays. You say that the services were necessary and there was no time 
to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the chest x-rays 
provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on September 1, 2022, to September 
8, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were unaware this provider was no longer 
in-network. 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 dental services provided on September 1, 2022, to September 8, 2022, by an out-of-network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
and intraoral - periapical each additional radiographic image (D0230) provided on November 2, 2022. 
 
You asked the Plan to pay for the intraoral - periapical first radiographic image (D0220), and intraoral - 
periapical each additional radiographic image (D0230). You say that the dental hygienist took an x-ray and said 
it was covered. You also say that if you would have known it was an intraoral-periapical first radiographic 
image you would have checked with the Plan. The Plan denied your request. The Plan says this service is not 
covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic 
image (D0230) provided on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on 
September 16, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you found a provider that had access to the hearing 
aid model that would be the best option. You say you want to be reimbursed, and only liable for the copayment. 
The Plan denied your request. The Plan says the provider was out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when received by a network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the provider was out-of-network. Therefore, we 
decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on 
September 16, 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 March 17, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you have not used all your dental benefits so the 
dental service should be covered. 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 the date of service of March 15, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341 x4) provided on October 19, 2022, and November 16, 2022. 
 
You asked the Plan to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341 
x4). You say that your Evidence of Coverage states you should only pay 75% of the charges. You also say that 
the services are necessary to avoid losing more of your teeth. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing - four or more teeth per quadrant (D4341 x4) provided on October 19, 
2022, and November 16, 2022.