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

 
We decided that the Plan does not have to waive the copayment for ambulance stabilization without transport 
provided on April 28, 2022. 
 
You asked the Plan to waive the copayment for ambulance stabilization without transport. You say that you 
were not transported via ambulance, and the providers who came with the transport did not help. Therefore, 
you feel you should not have to pay this copayment. The Plan denied your request. The Plan says the 
copayment applied was correct. 
 
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 ambulance stabilization without transport. Ambulance 
stabilization without transport 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 ambulance stabilization without transport provided on April 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray on April 20, 2022. 
 
You asked the Plan to waive the copayment for x-ray. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
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 diagnostic procedures and tests at specialists office. Covered services include but are not 
limited to X-rays. The provider billed in the amount of $211 and the Plan paid $183.19. $211 - $183.19 = 
$27.81. This is less than the copayment amount. Therefore, results in the total cost sharing amount of $27.81. 
 
You have been asked to pay a $27.81 copayment, which is less than the copayment for x-ray. X-rays fall within 
the Outpatient diagnostic tests and therapeutic services and 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 copayment for x-ray on April 20, 2022.
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 April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the care you received was appropriate and 
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 date of service April 20, 2022. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused 
(D0140) provided April 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 29, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should not have to pay this as 
the service wasn't done at the time of your visit. The Plan denied your request. The Plan says the copayment 
applied was correct. Per medical records, this exam did happen. 
 
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 $50 
copayment for In-network Medicare-covered standard x-ray and ultrasound.  
 
You have been asked to pay a $50 copayment for an ultrasound. An ultrasound falls within the Outpatient 
Diagnostic Tests, In-Network Medicare-Covered Standard X-Ray and Ultrasound benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an ultrasound provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for an Out-of-Network specialist visit provided 
on January 18, 2022. 
 
You asked the Plan to lower the copayment for an Out-of-Network specialist. You say that you already paid 
$20 at the time of the visit, you do not feel you should have to pay an extra $30. The Plan denied your request. 
The Plan says the copayment applied was correct. 
 
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 $50 
copayment for an Out-of-Network specialist visit.  
 
You have been asked to pay a $50 copayment for an Out-of-Network specialist. An Out-of-Network specialist 
falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to lower the copayment for an Out-of-Network specialist visit provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 3, 
2022, and January 8, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that any other time you have gone 
to urgent care, it was a $15 copayment, not $30. The Plan denied your request. The Plan says the copayments 
applied were correct. 
 
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 $30 
copayment for urgently needed services.  
 
You have been asked to pay a $60 copayment for urgent care visits ($30 x 2 visits = $60). An urgent care visit 
falls within the Urgently Needed 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 an urgent care visit provided on January 3, 2022, and January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for infusion on February 02, 2022. 
 
You asked the Plan to waive the copayment for infusion. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing amount you are being charged is correct. 
 
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 $345 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges. The provider billed the in 
the amount of $548.00 and the allowed amount is $204.99. This is less than the copayment amount. Therefore, 
results in the total cost sharing amount of $204.99. 
 
 
 
 You have been asked to pay a $204.99 copayment, which is less than the copayment for infusion. Infusions fall 
within the Outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 infusion on 
February 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation - per site 
(D7953). 
 
You asked the Plan to pre-approve the bone replacement graft. You say that you need this service done because 
you have a big hole under your gum line. The Plan denied your request. The Plan says the service requested is 
not a covered benefit under your dental plan.  
 
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 pre-approve bone 
replacement graft for ridge preservation - per site (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on March 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 office services provided on April 28, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office services. You say that this provider was listed as in-network. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because this provider is 
out-of-network with the Plan and authorization was not obtained. 
 
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 office services provided on April 28, 2022 by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revascularization procedure of the lower extremities 
for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that they made attempts to obtain information and did not get a response in order to 
support medical need. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met.  
 
We looked at the file and Medicare rules. Specifically, medical records were not provided for review in this 
case. The record shows that the Plan made multiple attempts to secure medical records, without success. 
Without medical records, we cannot determine if Medicare criteria are met in this case. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a revascularization procedure of the lower extremities for 
the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for services provided from April 5, 2022, to 
April 29, 2022. 
 
You asked the Plan to waive the cost-share for services. You say that you are not able to afford the cost due to 
being on a fixed income. The Plan denied your request. The Plan says the cost-share applied is correct. 
 
  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 intravenous, subcutaneous, and biological Part B drugs, a $10 copayment for specialty care 
physician, a $10 copayment outpatient diagnostic tests, and a $100 copayment for diagnostic radiology.  
 
You have been asked to pay $354.24 for services provided from April 5, 2022, to April 29, 2022. 
 
Date of Service Service Allowed 
Amount 
Cost Per Contract Member Liability 
April 5, 2022 Prostate Needle Biopsy (55700) $233.90 $10 Copayment $10 
April 5, 2022 Injection (J1580) $1.56 20% $0.31 
April 5, 2022 Transrectal Ultrasound (76872) $199.67 $10 Copayment $10 
April 5, 2022 Therapeutic Injection (96372) $13.81 $10 $2.76 
April 12, 2022 Technetium TC-99m (A9503) $49.80 20% $9.96 
April 12, 2022 Bone & Joint Imaging (78306) $273.44 $100 Copayment $100 
April 15, 2022 Specialist Visit (99214) $123.42 $10 Copayment $10 
April 19, 2022 Computed Tomography (CT) 
Scan (74177) 
$315.12 $100 Copayment $100 
April 22, 2022 Office Visit (99205) $211.11 $10 Copayment $10 
April 29, 2022 Chemotherapy Administration 
(96402) 
$31.88 $10 Copayment $10 
April 29, 2022 Injection (J9217) $506.07 20% $101.21 
TOTAL:    $354.24 
 
The injections fall within the Medicare Part B Prescription Drugs benefit category. The ultrasound, bone & 
joint imaging and CT scan fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. The prostate needle biopsy, office visits, therapeutic injection and chemotherapy 
administration fall within the Physician/Practitioner Services, Including Doctors Office Visits, benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the cost-share for services provided from April 5, 2022, to April 
29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychological testing evaluation services provided on 
May 4, 2022. 
 
You asked the Plan to pay for psychological testing evaluation services. The Plan denied your request. The 
Plan says 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 Plan says that the Plan has also determined that these services 
are not urgent or emergent, nor were they 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychological testing evaluation services provided on  
May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for multiple dental services (D6011, D1330, D6057, and D6059) 
from March 8, 2022, to April 20, 2022. 
 
You asked the Plan to pay for multiple dental services (D6011, D1330, D6057, D6059, D2740, and D2950). 
You say that you would like to appeal the denial of the claim. The Plan denied your request. The Plan says 
dental services (D6011, D1330, D6057, and D6059) are not covered under the member's dental plan under any 
circumstances, while dental services (D2740, and D2950) are to be reprocessed as these are covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for multiple 
dental services (D6011, D1330, D6057, and D6059) from March 8, 2022, to April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 8, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you thought this visit would not 
have a copayment, as it was a follow up for surgery. The Plan denied your request. The Plan says the 
copayment applied was correct. 
 
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 $25 
copayment for specialist physician/practitioner services, including doctors office visits.  
 
You have been asked to pay a $25 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0366) provided on March 21, 2022, 
and an implant (D6010), a bone graft (D6104), and a surgical implant index (D6190) provided on March 28, 2022. We also decided that the Plan does not have to waive the coinsurance for an extraction (D7210) provided 
on March 28, 2022. 
 
You asked the Plan to pay for imaging, implant services, and a graft. You also asked the Plan to waive the 
coinsurance for an extraction. You say that you do not understand why you could not go to a different dentist 
for emergency treatment. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount for an extraction. The Plan also says that cone beam imaging (D0366), an implant (D6010), a 
bone graft (D6104), and a surgical implant index (D6190) are not covered by your routine dental benefits. 
 
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 50% 
coinsurance for an extraction.  
 
You have been asked to pay $71, which is 50% coinsurance of the allowed amount for an extraction ($142 
allowed amount x 50% coinsurance = $71). An extraction falls within the Dental 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.  
 
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, cone beam imaging, implants, bone 
grafts, and implant indexes are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for cone beam imaging (D0366) provided on March 21, 2022, and an implant (D6010), a 
bone graft (D6104), and a surgical implant index (D6190) provided on March 28, 2022. We also decided that 
the Plan does not have to waive the coinsurance for an extraction (D7210) provided on March 28, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on March 7, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. You state that the enrollee should not have to change their doctor because 
they do not have OON benefits. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 outpatient mental health services provided on 
March 7, 2022, by an out-of-network (OON) provider.