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

 
We decided that the Plan does not have to pay for the laboratory services provided on August 02, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that your PCP could not find a dermatologist 
within a reasonable distance. 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 laboratory services 
provided on August 02, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays provided on July 07, 2022. 
 
You asked the Plan to pay for the x-rays. You say that you were informed that the facility was in-network. 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 x-rays provided on 
July 07, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on July 22, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this 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 $250 
copayment for Ambulance services. 
 
You have been asked to pay a $250 copayment for ambulance transport. 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 ambulance transport 
provided on July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit by the Plan or by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (85060) provided on July 3, 2022. 
 
You asked the Plan to pay for procedure code 85060. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical 
Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the 
professional component of this procedure is only payable for inpatients. The services were billed with an outpatient place of service. Payment for this service cannot be made for hospital outpatients. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (85060) provided on July 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on February 8, 2022, to July 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on February 8, 2022, to July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) and a periapical x-ray (D0230) 
provided on September 28, 2022. 
 
You asked the Plan to pay for the x-rays. You say that the panoramic x-ray was ordered as an emergency dental 
visit, not preventive. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 a panoramic x-ray was exhausted on date of service July 24, 2019. The record also 
shows your benefit for a periapical x-ray was exhausted on date of service September 28, 2022. Therefore, we 
decided that the Plan does not have to pay for a panoramic x-ray (D0330) and a periapical x-ray (D0230) 
provided on September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (85060) provided on July 7, 2022. 
 
You asked the Plan to pay for procedure code 85060. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical 
Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the 
professional component of this procedure is only payable for inpatients. The services were billed with an outpatient place of service. Payment for this service cannot be made for hospital outpatients. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (85060) provided on July 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee provided on 
April 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are not sure why a bill was received. 
The Plan denied your request. The Plan says the facility is out-of-network and authorization was not obtained 
prior to services being rendered. Network facilities were available to provide necessary care. 
 
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 laboratory services provided to the enrollee 
provided on April 8, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
September 8, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you went to have a crown re-
attached on August 17, 2022, and did not receive an exam or cleaning that day. You also say when you went 
for your annual routine cleaning on this date of service at appeal, you were advised that the previous provider 
had charged you for the routine exam, and your coverage had been denied. 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 August 17, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on September 8, 2022.  
 Your complaint about being unfairly charged for a service you did not receive is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on July 
30, 2022. 
 
You asked the Plan to waive the copayment for emergency room 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 $50 
copayment for emergency care.  
 
You have been asked to pay a $50 copayment for emergency room services. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency room services 
provided on July 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) 
provided on February 24, 2022. 
 
You asked the Plan to pay for the CT of the head or brain. You say that you would like this claim to be 
reconsidered. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the enrollees terminal condition.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) 
provided on February 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on April 02, 2022, to April 
05, 2022. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you are appealing the claim payment denial. 
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 inpatient hospital stay 
provided on April 02, 2022, to April 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the apicoectomy (D3410) provided on August 22, 2022. 
 
You asked the Plan to pay for the apicoectomy. You say that at no time did you have a procedure that was an 
elected or in cosmetic of nature. You also say that this surgery was medically necessary to the well-being of 
your health. The Plan denied your request. The Plan says this service 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 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 the 
apicoectomy (D3410) provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on April 19, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this service is not 
a Medicare covered benefit, and is excluded from coverage under your plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The record shows you received a medical eye exam for the diagnoses 
of Non-exudative age-related macular degeneration bilateral, Dry eye syndrome of bilateral lacrimal glands, 
Type 2 diabetes mellitus without complications, and Presence of intraocular lens. The refraction has to be 
performed with a routine eye exam to be covered. Based on this information, we decided that the Plan's rules 
for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay 
for the eye refraction (92015) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on April 27, 2022, to May 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 the dental 
services on April 27, 2022, to May 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140), periapical radiographic image 
(D0220), and resin-based composites (D2391 and D2392) for tooth #2 and #28 provided on November 18, 
2021. 
 
You asked the Plan to pay for the dental services. You say that you did not know you could exceed limitations 
on dental services. The Plan denied your request. The Plan says your benefit for the requested items or services 
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 periapical radiographic image was exhausted on the date of service of February 9, 
2021, your benefit for the resin-based composites was exhausted on the date of service of February 18, 2021, 
and your benefit for the oral evaluation was exhausted on the date of service of July 20, 2021. Therefore, we 
decided that the Plan does not have to pay for an oral evaluation (D0140), periapical radiographic image 
(D0220), and resin-based composites (D2391 and D2392) for tooth #2 and #28 provided on November 18, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital facility visit provided on 
March 22, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital facility. You say that you should not be 
charged for the treatment room. 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 $275 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay $256.87, which is less than the standard $275 copayment for outpatient hospital 
facility. This outpatient hospital facility falls within the Outpatient surgery, including 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 outpatient hospital facility visit provided on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D2740 and D2952) on June 20, 2022. 
 
You asked the Plan to pay for the dental services (D2740 and D2952). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the requested 
service (D2740) has already been exhausted and the dental service (D2952) is not a covered service. 
 
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 October 7, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services (D2740 and D2952) on June 
20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
March 21, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that this bill is confusing 
you and you are not sure which amount to pay. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for an emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit 
provided on March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing service (V5299), hearing aids (V5130), and sales 
tax (S9999) provided on July 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing service, hearing aids, and sales tax. You say that the company the 
Plan uses for hearing aids costs too much, and they want to finance the rest of the bill after the Plan pays. You 
also say that you are on a fixed income and cannot afford to finance hearing aids. The Plan denied your request. 
The Plan says you purchased your hearing aids from an OON provider. The Plan also says hearing aids are not 
covered OON. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's approved hearing aid vendor. The rules also says that Medicare does 
not make separate payment for sales tax. 
 
 
 We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing service, hearing aids, and sales tax have not been met. Therefore, we decided that the 
Plan does not have to pay for the hearing service (V5299), hearing aids (V5130), and sales tax (S9999) 
provided on July 21, 2022, by an out-of-network (OON) provider.