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

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on July 29, 2022. 
 
You asked the Plan to waive the copayment for urgent care visit. 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 $25 
copayment for urgently needed services.  
 
You have been asked to pay a $25 copayment for 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 urgent care visit provided 
on July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 13, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 20, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
under the impression that you would not be charged for emergency medical service visits unless you were 
treated and transported. The Plan denied your request. The Plan says the ambulance was called, and you were 
not transported to an emergency facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 20, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on August 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up services and a crown (D2950, D2740) provided 
on April 18, 2022 
 
You asked the Plan to pay for the core build up services and a crown. 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 core build 
up services and a crown (D2950, D2740) provided on April 18, 2022
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from July 31, 
2021, through August 4, 2021. The Plan says, per Medicare guidelines, the provider must bill Original 
Medicare for the services provided on August 5, 2021. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on August 4, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on August 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on August 
12, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $275 
copayment for outpatient surgery/Medicare-covered surgery.  
 
You have been asked to pay a $275 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicare-covered surgery 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 outpatient surgery provided on August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral examination (D0120) and the cleaning (D1110) 
provided on August 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you specifically told the dental office that you 
only want what is covered by your insurance. 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 February 28, 2022. 
Therefore, we decided that the Plan does not have to pay for the oral examination (D0120) and the cleaning 
(D1110) provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services and zirconia coping on crown (D2950, 
D0001, D0033) provided on May 23, 2022. 
 
You asked the Plan to pay for the core buildup services and zirconia coping on crown. 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 core 
buildup services and zirconia coping on crown (D2950, D0001, D0033) provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 08, 2022. 
 
You asked the Plan to pay for office visit. You say that this service has been covered in the past. 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 office visit provided on 
June 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 3, 
2022. 
 
You asked the Plan to pay for the evaluation. You say that you disagree with the denial of the evaluation. 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 19, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
August 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on May 9, 2022. 
 
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says self-
administered drugs are not a covered benefit while under an outpatient hospital stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on May 9, 2022.  
 
  Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health skilled nursing care provided on December 5, 
2020. 
 
You asked the Plan to pay for the home health skilled nursing care. You say that you are appealing the denial 
of home health care services and have submitted supporting documentation for review. The Plan denied your 
request. The Plan says the claim was not received within the allowed 12 months from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the home health skilled nursing care was not filed until February 25, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for home health skilled nursing care provided on 
December 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial denture (D5213) provided on August 16, 2022 
 
You asked the Plan to pay for the partial denture. 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 partial 
denture (D5213) provided on August 16, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and resin-based 
composite (D2332) provided on September 28, 2022. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and resin-based composite. You say that you 
paid all but $68.00 which insurance was to cover. The Plan denied your request. The Plan says the provided 
services are not covered benefits 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. 
 
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 first 
intraoral periapical x-ray (D0220) and resin-based composite (D2332) provided on September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 28, 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 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 9, 2021. Therefore, 
we decided that the Plan does not have to pay for the dental services on September 28, 2022.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from June 29, 2021, to July 28, 2021, until the claim is reviewed by Original Medicare.
You asked the Plan to pay for home health services provided from June 29, 2021, to July 28, 2021. The Plan denied your request. The Plan states the provider has not followed the correct Medicare billing guidelines. The Plan notes the provider should not be billing the Plan for the entire claim. One claim should have been sent to Original Medicare for June 29, 2021, and June 30, 2021, and one claim should have been submitted to the Plan for July 1, 2021, to July 28, 201. Plan cannot spit the payment and must wait for Original Medicare to review their portion first.
The Plan is correct in this case. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on June 2, 2021. Two claims were required for these services based on the Medicare billing guidelines. Therefore, we decided the Plan does not have to pay for home health services billed on one claim for dates of service June 29, 2021, to July 28, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services billed with DRG 091 provided from 
January 26, 2021, to February 4, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the DRG was updated. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Despite having medical information available for their review, the plan did not 
provide any medical records for MAXIMUS review. There is no way to determine if the plan's revised DRG of 
947 is appropriate in this case. Therefore, we decided that the Plan has to pay for the inpatient hospital services 
billed with DRG 091 provided from January 26, 2021, to February 4, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DNA gene analysis provided on September 22, 2022. 
 
You asked the Plan to pay for DNA gene analysis. You say that the service was medically necessary. 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 DNA gene analysis 
provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient eye exam (92004), determination of 
refractive state (92015), and eye exam with photos (92250) provided on August 11, 2022, by an out-of-network 
(OON) provider. 
 You asked the Plan to pay for the eye exam, refraction and exam with photos. You say that you would like 
these services to be covered. The Plan denied your request. The Plan says these services are not covered when 
provided OON without prior authorization. 
 
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. The Plan covers these services when provided by a vision network provider. 
 
We looked at the file and the Plan's rules. In this case the services were provided OON.  Based on this 
information, we decided that the Plan's rules for coverage of the eye exam, refraction and exam with photos 
have not been met. Therefore, we decided that the Plan does not have to pay for the new patient eye exam 
(92004), determination of refractive state (92015), and eye exam with photos (92250) provided on August 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for primary care visit provided on August 24, 
2022. 
 
You asked the Plan to waive the copayment for primary care visit. 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 $10 
copayment for physician/practitioner services/primary care visit.  
 
You have been asked to pay a $10 copayment for primary care visit. This item/service falls within the 
physician/practitioner services/primary care visit 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 primary care visit provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the outpatient clinic visit provided on 
August 09, 2022. 
 
You asked the Plan to waive the deductible for the outpatient clinic visit. You say that you should only have a 
$10 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 $550 
deductible for outpatient hospital services. 
 
You have been asked to pay a $550 deductible for the outpatient clinic visit. 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 deductible for the 
outpatient clinic visit provided on August 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear provided on September 21, 2022. 
 
You asked the Plan to pay for the eyewear. You say that you received a new pair of eyeglasses because your 
old ones were no longer good. You say your benefits were verified and were told you were eligible. The Plan 
denied your request. The Plan says the service is a covered benefit, but you have exceeded the benefit limits. 
 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. The Plan covers these services every two years. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid for eyewear received on November 27, 
2021. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been 
met. Therefore, we decided that the Plan does not have to pay for the eyewear provided on September 21, 2022.