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

 
We decided that the Plan does not have to pre-approve power seat elevation feature (E2300) power standing 
feature (E2301) wheelchair component or accessory, not otherwise specified, electric leg bag emptier (K0108) 
wheelchair component or accessory, not otherwise specified, bag hooks (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the medical records provided 
support the necessity of the requested services. The Plan denied your request. The Plan says these items are not 
primarily medical in nature and are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve power seat elevation feature (E2300) power standing feature (E2301) wheelchair component or 
accessory, not otherwise specified, electric leg bag emptier (K0108) wheelchair component or accessory, not 
otherwise specified, bag hooks (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and extractions (D7210) 
provided by an out-of-network provider on May 26, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and extractions. You say that you thought that this 
would be covered. The Plan denied your request. The Plan says services provided by an out-of-network 
provider are not covered. 
 
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 a limited 
number of benefits provided by participating providers.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a limited oral evaluation and extractions have not been met. Therefore, we decided that the Plan 
does not have to pay for a limited oral evaluation (D0140), and extractions (D7210) provided by an out-of-
network provider on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220) and root canal (D3330) 
provided from December 29, 2021, to December 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not able to find an in network 
provider. You also say that you feel you were misled. The Plan denied your request. The Plan says dental 
services are only covered when received by a participating 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 periapical x-ray is not among those 
covered under this benefit regardless of the provider's network status. Additionally, the root canal is not 
covered when performed by an out of network provider.  Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220) and root canal (D3330) provided from December 29, 2021, to December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D6750), and a pontic (D6240) provided by a 
participating provider on June 30, 2021. 
 
You asked the Plan to pay for a crown (D6750), and a pontic. You say that you would not have had this work 
done if you knew that it would not be approved. The Plan denied your request. The Plan says the rendered 
dental work are not covered 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 crown 
(D6750), and a pontic (D6240) provided by a participating provider on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided November 23, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you were told this service would be covered. 
The Plan denied your request. The Plan says they did not find evidence that incorrect information was given. 
This service is not covered under your 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 pay for the 
limited oral evaluation - problem focused (D0140) provided November 23, 2021.  
Your complaint about potentially receiving misinformation from a plan representative 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown (D6065) 
provided September 1, 2021. 
 
You asked the Plan to pay for the implant supported crown. You say that this service was necessary. The Plan 
denied your request. The Plan says this service is not covered under your 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 pay for the 
implant supported porcelain/ceramic crown (D6065) provided September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the four crowns - porcelain fused to 
high noble metal (D2750) provided November 18, 2021. 
 
You asked the Plan to provide additional payment for the four crowns. You say that you were told you were 
covered for crowns. The Plan denied your request. The Plan says the copayment for the crowns was assessed 
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. The Plan covers the four 
crowns with a $125 copayment.  
 
We looked at the file and Medicare rules. You have been asked to pay a total of $500 ($125 copayment x 4 
crowns = $500). This means you have been asked to pay the correct amount for the crowns. Therefore, we decided that the Plan does not have to provide additional payment for the four crowns - porcelain fused to high 
noble metal (D2750) provided November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
September 22, 2021. 
 
You asked the Plan to pay for dental services. You say that you were comfortable with this dentist. The Plan 
denied your request. The Plan says services provided by an out-of-network provider are not covered 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 Plan covers dental 
services when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on September 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
July 5, 2021, to July 9, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were not in the 
ICU. You say that you cannot afford the copayment. 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 $150 per 
day for days 1-7 and $0 per day for days 8-90 for each inpatient stay.  
 
The file shows that you were admitted to the hospital from July 5, 2021, to July 9, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $150 per day for the first 4 days of inpatient hospital services. The total for your stay is $600 ($150 copayment x 4 days = $600). The inpatient 
hospital services fall within the Inpatient Hospital Care benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for inpatient hospital services provided from July 5, 2021, to July 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for an office visit provided on December 6, 2021. 
 
You asked the Plan to reduce the copayment for an office visit. You say that this was a PCP office visit, so the 
charges should be reduced. The Plan denied your request. The Plan says that the copayment amount charged is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $10 copayment for each covered visit or consultation in an 
outpatient location with your PCP or other primary care provider.  
 
The Plan says you must pay a $40 copayment for an office visit. Based on the Plan contract, however, you 
cannot be asked to pay more than a $10 copayment for an office visit. Therefore, we decided that the Plan has 
to reduce the copayment for an office visit provided on December 6, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on November 19, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home visit. You say that the hospital did not obtain authorization for the 
services. 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 the home visit provided on November 19, 2021, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
September 28, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $150 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $121 copayment for the outpatient hospital visit, which is less than the standard 
$150. 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 hospital visit provided on 
September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Lab testing provided on December 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Lab testing. You say that you are requesting reconsideration of the denial of the 
claim. The Plan denied your request. The Plan says the claim for services provided on December 22, 2021 was 
processed correctly. 
 
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 Lab testing provided on December 22, 2021 by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility health care visit provided on September 27, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a facility health care visit. You say that it is the facilities responsibility to get the 
authorized approval in advance and the service provided was out of medical necessity. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network provider and there was no referral from an 
in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 facility health care visit provided on September 
27, 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 deductible for anesthesia services provided on October 20, 
2021. 
 
You asked the Plan to waive the deductible for the anesthesia services. You say that the services should be 
covered as you had no choice but to go out-of-network. The Plan denied your request. The Plan says the 
deductible applied correctly and would have been assessed regardless of if services were rendered in or out-of-
network. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to Outpatient hospital services.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1,000 deductible which applies to Outpatient hospital services. This cost sharing is a contractual obligation 
that had not been met at the time the anesthesia services was received on October 20, 2021. Therefore, we 
decided that the Plan does not have to waive the deductible for anesthesia services provided on October 20, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for inpatient hospital services provided from 
April 21, 2021, to May 27, 2021. 
 
You asked the Plan to waive the copayments for the inpatient hospital services. You say that all treatments 
were COVID-19 related. 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 $125 
copayment for each hospital stay.  
 
The file shows that the Plan verified COVID-19 treatment on April 21, 2021, and reprocessed the claim to 
remove all cost sharing. The file also shows that the Plan verified your inpatient admission on May 12, 2021, and removed the copayment for the emergency room (ER) visit. Since the inpatient treatments on May 12, 
2021, and May 27, 2021, were related to COVID-19 complications only, you have been asked to pay a $125 
copayment for each of the inpatient hospital services. The total for both stays is $250 ($125 copayment x 2 
days = $250). The inpatient hospital services fall 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 copayments for inpatient hospital services provided from April 21, 2021, to 
May 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
12, 2021, to June 9, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, no valid 
RAP has been submitted. Therefore, we decided that the Plan does not have to pay for the home health services 
provided to the enrollee from May 12, 2021, to June 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for outpatient surgery provided by a network facility on 
October 12, 2021. 
 
You asked the Plan to waive the cost share for outpatient surgery. Please note, the Plan did not submit your 
appeal request. The Plan denied your request. The Plan says that you have been charged the correct cost 
sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit the complete Evidence of Coverage. This means we are 
unable to determine if the deductible amount you are being asked to pay is correct. Therefore, we decided that 
the Plan has to waive the cost share for outpatient surgery provided by a network facility on October 12, 2021. 
  
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
August 13, 2021, to August 15, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the provider 
informed you that you would only have a $300 copayment. 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 $285 per 
day for days 1-6 and $0 per day for days 7-90 for each inpatient stay.  
 
The file shows that you were admitted to the hospital from August 13, 2021, to August 15, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $285 per day for the first 2 days of inpatient hospital services. The total for your stay is $570 ($285 copayment x 2 days = $570). The inpatient 
hospital services fall within the Inpatient Hospital Care benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for inpatient hospital services provided from August 13, 2021, to August 15, 2021.