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

 
We decided that the Plan does not have to waive the copayment for the ambulance service provided on 
December 02, 2022. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that you feel the hospital 
should pay for the ambulance since they could not provide the services you needed there. 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 $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for the ambulance service. This item/service falls within the 
ambulance services 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 ambulance 
service provided on December 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on November 22, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that we depend on the facility staff to verify 
eligibility and 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 a nursing facility visit 
provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on September 26, 2022. 
 
You asked the Plan to pay for dental services. You say that the enrollee needs the services, and you think 
insurance should cover them. The Plan denied your request. The Plan says these services are not authorized. 
Dental services or oral surgery, rendered by a physician or dental professional, are covered only for treatment 
of primary medical conditions. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on 
September 26, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physiologic monitoring treatment provided on August 30, 
2022. 
 
You asked the Plan to pay for physiologic monitoring treatment. 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 physiologic monitoring 
treatment provided on August 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Freestyle Libre sensor provided on February 17, 2022. 
 
You asked the Plan to pay for the Freestyle Libre sensor. You say that you disagree with this denial. The Plan 
denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre sensor have not been met. Therefore, we decided that the Plan does not have to pay for the 
Freestyle Libre sensor provided on February 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on November 14, 
2022. 
 
You asked the Plan to waive the copayment for x-ray services. 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 $15 
copayment for outpatient diagnostic tests/X-ray. 
 
You have been asked to pay a $15 copayment for x-ray services. This item/service falls within the outpatient 
diagnostic tests/X-ray 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 x-ray 
services provided on November 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on August 22, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that previous claims for this enrollee have 
been paid. 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 psychotherapy 
services provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the intraoral 
radiographic image (D0220) provided on December 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you never used your benefit prior to the service 
so it is not possible for you to reach your maximum benefit. The Plan denied your request. The Plan says your 
annual allowance 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. On 
December 1, 2022, the Plan paid $1,000 for a crown and core buildup; therefore, your maximum dental benefit 
for the year was exhausted on the date of service of December 1, 2022. Therefore, we decided that the Plan 
does not have to pay for a limited oral evaluation (D0140) and the intraoral radiographic image (D0220) 
provided on December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram provided on September 02, 2022. 
 
You asked the Plan to pay for electrocardiogram. 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 electrocardiogram 
provided on September 02, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment; methadone (G2067) provided on 
October 3, 2022. 
 
You asked the Plan to pay for medication assisted treatment; methadone. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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 facility where the provider rendered the services is enrolled with Medicare 
as an OTP. The OTP is the billing provider and is Substance Abuse and Mental Health Services Administration 
(SAMHSA) certified. The rules cited by the Plan do not provide a valid reason to deny this claim given that the 
OTP meets the Medicare coverage criteria. Therefore, we decided that the Plan has to pay for medication 
assisted treatment; methadone (G2067) provided on October 3, 2022.   
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 waive the cost sharing for the specialist visits provided by an out-of-
network provider from February 4, 2022, to November 18, 2022, the joint injections, and the triamcinolone 
acetonide injections provided by an out-of-network provider on February 4, 2022, and May 25, 2022. 
 You asked the Plan to waive the cost sharing for the specialist visits, the joint injections, and the triamcinolone 
acetonide injections. You say that you were told that this provider was in-network. 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% 
coinsurance of the total allowed amount, per provider per day, for each out-of-network Medicare-covered 
specialist office visit, a 45% coinsurance of the total allowed amount for out-of-network Medicare-covered 
surgical services performed at an ambulatory surgical center, and a 45% coinsurance of the total allowed 
amount for other out-of-network Medicare-covered Part B drugs and their administration. 
 
You have been asked to pay a $83.74 coinsurance for the specialist visits. The Plan is only holding you 
responsible for less than the 45% coinsurance for the specialist visit on November 18, 2022. These 
items/services fall within the physician/practitioner services, including doctors office visits benefit category. 
You have been asked to pay a $71.96 coinsurance for the joint injections. These items/services fall within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. You have also been asked to pay a $8.53 coinsurance for the triamcinolone acetonide 
injections. These items/services fall within the Medicare Part B prescription drugs benefit category. 
 
Date of Service Item/Service Allowed Amount Coinsurance Your Responsibility 
February 4, 2022 Specialist Visit $46.53 x .45 $20.94 
February 4, 2022 Joint Injection $79.96 x .45 $35.98 
February 4, 2022 
Triamcinolone 
Acetonide Injections 
$11.33 x .45 $5.10 
May 25, 2022 Specialist Visit $46.53 x .45 $20.94 
May 25, 2022 Joint Injection $79.96 x .45 $35.98 
May 25, 2022 
Triamcinolone 
Acetonide Injections 
$7.63 x .45 $3.43 
September 21, 2022 Specialist Visit $46.53 x .45 $20.94 
November 18, 2022 Specialist Visit $46.53 x .45 $20.92 
 
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 specialist visits provided by an out-of-network provider 
from February 4, 2022, to November 18, 2022, the joint injections, and the triamcinolone acetonide injections 
provided by an out-of-network provider on February 4, 2022, and May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment of root canal obstruction, non-surgical access 
(D3331) and non-intravenous conscious sedation (D9248) provided on June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service was medically necessary in order to 
have a root canal done to prevent infection. The Plan denied your request. The Plan says general anesthesia and 
the services of a special anesthesiologist, intravenous and inhalation sedation, and prescription drugs for dental 
procedures are excluded from coverage regardless of medical necessity. 
 
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 treatment 
of root canal obstruction, non-surgical access (D3331) and non-intravenous conscious sedation (D9248) 
provided on June 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on October 
29, 2022. 
 
You asked the Plan to pay for procedure code 99232. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee had a different insurance carrier at 
the time of the service as their primary payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has sent the 
explanation of benefits (EOB) directly to the primary insurer for payment and the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for procedure code 99232 until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on October 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on October 17, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that you are a participating provider with 
Medicare. 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 chiropractic services 
provided on October 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a computed tomography (CT) scan and 
medical supplies provided on September 15, 2022. 
 
You asked the Plan to waive the cost share for a CT scan and medical supplies. You say that you disagree with 
the cost share. 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 outpatient diagnostic tests/medical supplies and a $125 copayment, for outpatient diagnostic 
tests/Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a 20% coinsurance for medical supplies and a $125 copayment for a CT scan. The 
total allowed amount for the medical supplies is $12. You are being asked to pay $2.40 ($12 x 20% = $2.40). 
The total amount you are being asked to pay is $127.40 ($125 + $2.40 = $127.40). 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 share for a computed tomography (CT) scan and medical supplies provided on September 15, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 02, 2022. 
 
You asked the Plan to pay for an office visit. You say that due to covid our office has been understaffed and 
were unable to obtain the proper paperwork. 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 November 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for resin-based composite - two surfaces, 
posterior (D2392) x2 provided on June 24, 2022. 
 
You asked the Plan to pay more for dental services. You say that you would like your insurance plan to 
reconsider paying for the service that you received. The Plan denied your request. The Plan says your $1,000 
maximum annual allowance has been met. 
 
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 contract also says you 
have $1,000 combined allowance for supplemental preventive and comprehensive dental services every year. 
Member is responsible for any amount over and above the allowance amount. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2392 is not among 
those covered under this benefit. The Plan has paid your $1,000 dental maximum benefit. Therefore, we 
decided that the Plan does not have the full amount for resin-based composite - two surfaces, posterior (D2392) 
x2 provided on June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (including elevation of a full thickness flap 
and closure)  one to three contiguous teeth or tooth bounded spaces per quadrant (D4261) and occlusal 
adjustment - limited (D9951) provided on December 2, 2021. 
 
You asked the Plan to pay for dental services. You say that oral health is a high priority, and you would like 
your insurance to cover the provided services. The Plan denied your request. The Plan says this service is not 
covered under your 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. Osseous surgery (including 
elevation of a full thickness flap and closure)  one to three contiguous teeth or tooth bounded spaces per 
quadrant (D4261) and occlusal adjustment - limited (D9951) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4261 and D9951 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
osseous surgery (including elevation of a full thickness flap and closure)  one to three contiguous teeth or 
tooth bounded spaces per quadrant (D4261) and occlusal adjustment - limited (D9951) provided on December 
2, 2021.