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

 
We decided that the Plan does not have to pay for a physician visit provided on February 28, 2022. 
 
You asked the Plan to pay for a physician visit. You say that you are requesting reconsideration for the denied 
claim. 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 physician visit 
provided on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable medical equipment provided on 
July 12, 2022, to July 25, 2022. 
 
You asked the Plan to waive the coinsurance for Durable medical equipment. You say that you were told there 
would be no charge for this. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for Durable medical equipment. This item/service falls within 
the Durable medical equipment (DME) benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for Durable medical equipment provided on July 12, 2022, to July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic eye imaging and testing provided on February 21, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic eye imaging and testing. You say that no one told you this facility, 
provider, or tests were out of network. The Plan denied your request. The Plan says there was no 
preauthorization by your primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility. 
 
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 diagnostic eye imaging and testing provided on 
February 21, 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 a provisional pontic (D6253) and a provisional retainer 
crown (D6253) provided on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because a 
provisional pontic and a provisional retainer crown are not covered by 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, 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 
provisional pontic (D6253) and a provisional retainer crown (D6253) provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
May 25, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you feel that you should 
have been advised the treating provider was OON. You also say that you will not pay for this service because 
you were unduly billed. The Plan denied your request. The Plan says this service is not a covered expense 
under your dental plan. The Plan also says that you did not contact the Plan prior to the date of service to verify 
benefits and provider eligibility. 
 
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 
complete series of intraoral x-rays (D0210) provided on May 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) and outpatient therapy visit provided on June 6, 2022, to 08/14/2022.

You asked the Plan to waive the copayment for SNF and outpatient therapy visit. You say that you disagree with the cost share. 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 $40 copayment per visit and a $0 copayment per day for days 1-20 and a $188 per day for days 21-100 for outpatient rehabilitation services/occupational therapy services and Skilled nursing facility (SNF) care. 

You have been asked to pay a $40 copayment per visit and a $0 copayment per day for days 1-20 and a $188 per day for days 21-100 for SNF and outpatient therapy visit. This item/service falls within the outpatient rehabilitation services/occupational therapy services and Skilled nursing facility (SNF) 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 skilled nursing facility (SNF) and outpatient therapy visit provided on June 6, 2022, to 08/14/2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided on July 11, 2022. 
 
You asked the Plan to waive the copayment for lab work. You say that you have been charged too many 
copayments for lab work and feel you have been overcharged. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $7.68 which is less than the $10 copayment for lab work. 
This item/service falls 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 lab work provided on July 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for neurophysiological testing provided to the 
enrollee on May 9, 2022. 
 
You asked the Plan to waive the coinsurance for the neurophysiological testing. You say that only a copayment 
should apply when services are provided in an office setting. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for non-radiological diagnostic services.  
 
 
  The enrollee has been asked to pay a 20% coinsurance for the neurophysiological testing. This item/service 
falls within the non-radiological diagnostic services benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the coinsurance for neurophysiological testing provided to the enrollee on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two adjunctive procedures (D9999 x2) provided on April 
15, 2022. 
 
You asked the Plan to pay for the adjunctive procedures. You say that the dentist made you new dentures at the 
cost of a reline, which was cheaper. You also say that you thought your insurance paid for new dentures, but 
your claim was denied. 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 two 
adjunctive procedures (D9999 x2) provided on April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 27, 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 February 15, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient office visit (99213) and 
scanning computerized ophthalmic diagnostic imaging (92134) provided on June 30, 2022. 
 
You asked the Plan to waive the copayments for the outpatient office visit and diagnostic imaging. You say that 
these charges were paid in the past by your previous insurance company, and by the Plan. 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 $75.00 
copay for each diagnostic procedure or test at a network doctor's office under the Outpatient diagnostic tests 
and therapeutic services and supplies benefit category and you must pay a $40.00 copay for each Medicare-
covered exam to treat an eye condition under the Vision care benefit category.  
 
 
 You have been asked to pay a $40 copay for the outpatient office visit and you have been asked to pay $39.25 
for the diagnostic imaging, which is less than the standard $75.00 copay. These services fall within the 
Outpatient diagnostic tests and therapeutic services and supplies and Vision care benefit categories. 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 copayments for the outpatient office visit (99213) and scanning computerized 
ophthalmic diagnostic imaging (92134) provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four additional intraoral periapical x-rays (D0230 x4) 
provided on September 6, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you were not advised by 
your dentist that they were going to complete more x-rays than what your policy covers. 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 September 6, 2022. 
Therefore, we decided that the Plan does not have to pay for the four additional intraoral periapical x-rays 
(D0230 x4) provided on September 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging provided on August 22, 2022. 
 
You asked the Plan to pay for imaging. You say that the facility is 2 blocks from where you live, so you 
thought it 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 imaging provided on 
August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you returned the non-usable dentures, and 
they are supposed to be checking on a refund. 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 October 12, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
lower partial denture (D5214).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for a transthoracic 
echocardiogram (TTE) with regadenoson injection and a myocardial perfusion imaging (SPECT) test provided 
from May 13, 2022, to May 16, 2022. 
 
You asked the Plan to waive the copayments and coinsurance for the TTE with injection and the SPECT test. 
You say that you do not understand the cost of the 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 (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for outpatient diagnostic tests including advanced imaging services and a 20% coinsurance for 
Medicare Part B prescription drugs.  
 
 You have been asked to pay a $50 copayment each for the TTE and the SPECT test. This item/service falls 
within the outpatient diagnostic tests including advanced imaging services benefit category. You have also 
been asked to pay a 20% coinsurance for the regadenoson injection. This item/service falls within the Medicare 
Part B prescription drugs 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 copayments and 
coinsurance for a transthoracic echocardiogram (TTE) with regadenoson injection and a myocardial perfusion 
imaging (SPECT) test provided from May 13, 2022, to May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction (92015) provided on September 6, 2022. 
 
You asked the Plan to pay for the refraction. You say that you were not advised that this service could be 
denied, and accepted the service in good faith that it would be covered. You also say that you feel the Plan 
should cover this service, as it was a direct result of an incorrectly administered prior exam. The Plan denied 
your request. The Plan says this claim processed correctly. 
 
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 one routine eye exam every calendar year. 
 
We looked at the file and the Plan's rules. The record shows that you received a routine eye exam on April 21, 
2022, and your routine eye exam benefit had been exhausted. Based on this information, we decided that the 
Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have 
to pay for the refraction (92015) provided on September 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 17, 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 August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Lumbar-sacral orthosis (LSO) (L0650), provided on 
August 19, 2022. 
 
You asked the Plan to pay for a LSO. You say that the item is medically necessary. The Plan denied your 
request. The Plan says a review of the member's claims history showed no medical history between the member 
and the prescribing provider. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. The prescribing provider claims they did not order this item and 
there is no evidence of face-to-face encounter within the past 6 months showing the medical necessity of this brace. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for a Lumbar-sacral orthosis (LSO) (L0650), 
provided on August 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and a complete intraoral x-ray series (D0210) provided on September 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were advised the dentist took your dental 
plan. 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 a comprehensive oral evaluation (D0150), prophylaxis (D1110), and a complete intraoral x-ray series 
(D0210) provided on September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete dentures - maxillary (D5110), and mandibular 
(D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you need new dentures as the ones you 
have do not fit correctly. 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 items or services was exhausted on date of service December 29, 2020. 
Therefore, we decided that the Plan does not have to pre-approve complete dentures - maxillary (D5110), and 
mandibular (D5120).