Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the partial lower denture (D5214) and the extractions 
(D7140 and D7210) for tooth #10 and #11 provided on November 15, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are appealing the coinsurance that 
was applied to the dental services. 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. Your 
contract with the Plan clearly says that you must pay a 70% coinsurance for partial dentures and a 50% 
coinsurance for extractions when provided by an in-network provider. The total allowed amount for the partial 
denture was $1,001 with a coinsurance amount of $700.70 ($1,001 total x 70% coinsurance). The total amount 
allowed for the extraction of tooth #10 was $94 with a coinsurance of $47 ($94 total x 50% coinsurance). The 
total amount allowed for the extraction of tooth #11 was $163 with a coinsurance of $81.50 ($163 total x 50% 
coinsurance). The total coinsurance amount for the dental services was $829.20 ($700.70 coinsurance + $47 
coinsurance + $81.50 coinsurance). 
 
You have been asked to pay a $700.70 coinsurance for the partial denture and a $128.50 coinsurance for the 
extractions. This item/service falls within the mandatory supplemental dental 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 pay more for the partial lower denture (D5214) and the extractions (D7140 and D7210) for 
tooth #10 and #11 provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gene analysis provided on November 29, 2022. 
 
You asked the Plan to pay for gene analysis. You say that you are unable to obtain prior authorization for 
specimens obtained during procedures. 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 gene analysis provided 
on November 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an magnetic resonance imaging (MRI) 
provided on February 14, 2022. 
 
You asked the Plan to waive the copayment for an magnetic resonance imaging (MRI). You say that you 
disagree with the copaymet. 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 $225 
copayment for outpatient diagnostic tests/Medicarecovered diagnostic radiology services. 
 
You have been asked to pay a $225 copayment for an magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests/Medicarecovered diagnostic radiology 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 magnetic resonance imaging (MRI) provided on 
February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on September 19, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
September 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 12, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the enrollee should only be 
responsible for one 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 $270 
copayment for each one-way Medicare-covered ambulance trip. 
 
You have been asked to pay a $270 copayment for ambulance services. This item/service falls within the each 
one-way Medicare-covered ambulance trip 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 services provided on July 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthoptic training to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve orthoptic training. You say that there are no in-network providers or 
facilities that can take care of your health issues. The Plan denied your request. The Plan says the service can 
be provided by an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
orthoptic training to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan and 
administrations of antibiotics, steroids, anti-inflammatory drugs or other therapeutic medications (D9612, 
D0364) provided on September 7, 2022. 
 
You asked the Plan to pay for the CT scan and drug administration. You say that the services should be covered 
as you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as 
they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam computed tomography (CT) scan and administrations of antibiotics, steroids, anti-inflammatory drugs or 
other therapeutic medications (D9612, D0364) provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a adjunctive pre-diagnostic test (D0431), gingival irrigation  
per quadrant (D4921 x4), and gingival irrigation  per quadrant (D9630 x2) provided on June 29, 2022. 
 
You asked the Plan to pay for codes D0431, D4921 and D9630. You say that you went in for a regular teeth 
cleaning and were under the impression it would be covered by your insurance. You also say that you feel the 
dentist did other things without asking you. The Plan denied your request. The Plan says these services are not 
covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
adjunctive pre-diagnostic test (D0431), gingival irrigation  per quadrant (D4921 x4), and gingival irrigation  
per quadrant (D9630 x2) provided on June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the specialist visit provided by an out-of-
network provider on October 27, 2022. 
 
You asked the Plan to waive the deductible for the specialist visit. You say that you do not understand the cost 
sharing applied 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 says that you must pay the full cost for 
covered services until you have paid the $500 deductible, and the deductible applies to out-of-network 
specialist visits. 
 
You have been asked to pay a $125.70 deductible for the specialist visit. The item or service you asked the Plan 
to waive the deductible for was provided by an out-of-network provider. The Plan has followed Medicare rules 
by clearly disclosing in the contract that there is a $500 deductible which applies to out-of-network specialist 
visits. This cost sharing is a contractual obligation that had not been met at the time the specialist visit was 
provided on October 27, 2022. Therefore, we decided that the Plan does not have to waive the deductible for 
the specialist visit provided by an out-of-network provider on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe the enrollee is eligible for the 
SSBCI benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for 
SSBCI benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not meet the 
intensive care management criteria listed in the EOC, which is 2 or more inpatient admission in the last 60 
days, or 3 or more emergency room visits in the last 60 days. Therefore, we decided that the Plan does not have 
to pre-approve the SSBCI benefits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on October 11, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that the service should be covered 
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 $390 
copayment for outpatient hospital services. 
 
You have been asked to pay a $390 copayment for outpatient surgery. This item/service falls within the 
outpatient hospital 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 outpatient 
surgery provided on October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre. 
 
You asked the Plan to pre-approve a Freestyle Libre. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says a continuous glucose monitor is not covered under Medicare if the 
member does not require frequent daily adjustments of insulin based on glucose testing results. 
 
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 require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre.
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 November 
01, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that due to unable to see your 
primary care provider, you were referred to urgent care and should not be charged 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 $10 
copayment for urgently needed services. 
 
You have been asked to pay a $10 copayment for an urgent care visit. This item/service 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 November 01, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ultrasound study of both 
arms and legs provided on October 04, 2022. 
 
You asked the Plan to waive the copayment for an in-network ultrasound study of both arms and legs. You say 
that your provider told you that you needed this test done, therefore, you should not have to pay a 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 $100 
copayment for advanced imaging services. 
 
You have been asked to pay a $100 copayment for an in-network ultrasound study of both arms and legs. This 
item/service falls within the advanced imaging 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 in-network ultrasound study of both arms and legs provided on October 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on November 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider said you needed surgery, and you 
were provided phone numbers, but you could not reach any providers. So, you think these services should be 
covered. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services provided on November 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified preventive procedure (D1999), surgical 
procedure for isolation of tooth with rubber dam (D3910), and gingivectomy or gingivoplasty to allow access 
for restorative procedure, per tooth (D4212) provided on November 3, 2022. 
 
You asked the Plan to pay for dental services. You say that you do not agree that these services are not covered 
under your insurance plan. The Plan denied your request. The Plan says these services are 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. Unspecified preventive 
procedure (D1999), surgical procedure for isolation of tooth with rubber dam (D3910), and gingivectomy or 
gingivoplasty to allow access for restorative procedure, per tooth (D4212) are not covered under the Plans 
dental benefits. 
 
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 
unspecified preventive procedure (D1999), surgical procedure for isolation of tooth with rubber dam (D3910), 
and gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212) provided on 
November 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a foot x-ray provided on September 02, 2022. 
 
You asked the Plan to pay for a foot x-ray. You say that you hurt yourself on a work trip, and you thought that 
you had out of state coverage. 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 foot x-ray provided on 
September 02, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cortisone injection (64483). 
 
You asked the Plan to pre-approve a cortisone injection. You say that the requested service is a medical 
necessity for you. The Plan denied your request. The Plan says no medical documentation was received 
showing that your doctor ordered a cortisone injection. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a cortisone injection have been met. 
Specifically, no medical records are available to support a physician order for a cortisone injection. Therefore, 
we decided that the Plan does not have to pre-approve a cortisone injection (64483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 20, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 20, 2022.