Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit and an electrocardiogram (ECG) provided 
on January 11, 2023. 
 
You asked the Plan to pay for a specialist visit and an electrocardiogram (ECG). You say that you do not agree 
with the denial of these services. 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 specialist visit and an 
electrocardiogram (ECG) provided on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), localized 
delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 
(D4381), and the periodontal maintenance (D4910) provided on December 20, 2022.   
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under the 
supplemental dental policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical 
application of fluoride varnish (D1206), localized delivery of antimicrobial agents via a controlled release 
vehicle into diseased crevicular tissue, per tooth (D4381), and the periodontal maintenance (D4910) provided 
on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of an impacted tooth-partially bony (D7230), 
consultation-diagnostic service provided by a dentist or physician other than requesting dentist or physician 
(D9310), and the therapeutic parenteral drug, single administration (D9610) provided on October 13, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under the 
supplemental dental policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the removal of an 
impacted tooth-partially bony (D7230), consultation-diagnostic service provided by a dentist or physician other 
than requesting dentist or physician (D9310), and the therapeutic parenteral drug, single administration 
(D9610) provided on October 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
November 04, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that these should be included 
in your annual wellness 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 $10 
copayment for outpatient diagnostic lab services. 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls within the 
outpatient diagnostic lab 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. The record shows that non-preventative lab services were received. Therefore 
this claim was approved and you are responsible for the cost share amount. Therefore, we decided that the Plan 
does not have to waive the copayment for the laboratory services provided on November 04, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mental health visit provided on January 12, 2023. 
 
You asked the Plan to pay for a mental health visit. You say that you have been seeing this provider for years. 
You do not know who these other providers are. 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 mental health visit 
provided on January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up services for teeth #22-26 (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
the enrollee does not meet the clinical requirements to be covered. 
 
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 dental 
services when the services are medically necessary and reasonable.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the plan requires that for core 
buildups to be allowed that there must be less than 50% remaining structure of the tooth.  In this instance, none 
of the teeth in question have less than 50% of the structure remaining.  As there is sufficient remaining 
structure on teeth #22-26, the Plan criteria would not be met. Requested service cannot be recommended at this 
time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve core buildup services for teeth #22-26 (D2950).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided on March 24, 2022. 
 
You asked the Plan to pay for cataract surgery. You say that this is supported in the records. 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 cataract surgery 
provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist telehealth visit provided on 
November 18, 2022, to December 02, 2022. 
 
You asked the Plan to waive the copayment for each specialist telehealth visit. You say that you were not 
informed of 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 $45 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for each specialist telehealth visit. This item/service falls within the in-network 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. The total amount you owe is $90 ($45 
copayment x 2 visits =$90). Therefore, we decided that the Plan does not have to waive the copayment for each 
specialist telehealth visit provided on November 18, 2022, to December 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) and intraoral - complete series of radiographic images (D0210) provided on August 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not agree with the denial of the 
requested services. 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. This benefit includes the 
requested comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of 
radiographic images (D0210) but each is limited to one procedure every three plan years. 
  We looked at the file, the Plans rules, and Medicares rules. You previously received covered comprehensive 
oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images 
(D0210) on October 12, 2021. Therefore, these benefits were exhausted as of October 12, 2021. Therefore, we 
decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150) and intraoral - complete series of radiographic images (D0210) provided on August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on August 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for chiropractic care. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 chiropractic care provided on August 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on February 17, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies do not require separate 
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 wound care supplies 
provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the domiciliary or rest home visit provided 
on December 12, 2022. 
 
You asked the Plan to waive the coinsurance for the domiciliary or rest home visit. You say that you did not 
receive a statement. 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 physician and professional services. 
 
You have been asked to pay 20% coinsurance for the domiciliary or rest home visit. This item/service falls 
within the physician and professional 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 coinsurance 
for the domiciliary or rest home visit provided on December 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
September 28, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that your 2023 benefits should 
apply to this service. 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 $440 
copayment for ambulance services. 
 
You have been asked to pay a $440 copayment for the ambulance services. 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. Benefits are applied based on the year that services are received. Therefore, we decided that the 
Plan does not have to waive the copayment for the ambulance services provided on September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on March 30, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that the supplies should not require 
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 wound care supplies 
provided on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation-per quadrant (D4921 x 4), drugs or 
medicaments dispensed in the office for home use (D9630), and the localized delivery of antimicrobial agents 
via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided on December 9, 
2022 and December 13, 2022. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these items/services are not covered 
under the supplemental dental policy.  
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 items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation-per quadrant (D4921 x 4), drugs or medicaments dispensed in the office for home use 
(D9630), and the localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue, per tooth (D4381) provided on December 9, 2022 and December 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
October 20, 2022, to October 30, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this was originally a 
claim for $600 and was later changed to $1,500. 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 $300 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says 
that you then pay a $0 copayment for days 6-90 of the same inpatient stay. You have been asked to pay a $300 copayment per day for days 1-5 of the inpatient hospital stay. These 
items/services fall within the inpatient hospital care benefit category. You have not been charged after day five 
and have not been charged for the day you were discharged. You have been asked to pay a total of $1,500 
($300 copayment per day x 5 days = $1,500). 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 inpatient 
hospital stay provided from October 20, 2022, to October 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
December 28, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that these should be included in your 
annual physical. 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 lab services.  Lab services are not included in your annual physical. You have been asked to pay a $10 copayment for the lab 
services. This item/service falls within the outpatient diagnostic tests and therapeutic 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 laboratory services provided on December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ventral and inguinal hernia repair provided on November 08, 
2022. 
 
You asked the Plan to pay for ventral and inguinal hernia repair. You say that you are requesting the submitted 
documentation be reviewed. 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 ventral and inguinal 
hernia repair provided on November 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 04, 2023. 
 
You asked the Plan to pay for the office visit. You say that this is your primary care doctor and you dont want 
to switch. 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 office visit provided 
on January 04, 2023.