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

 
We decided that the Plan does not have to pay for a retainer crown - porcelain/ceramic tooth #'s 13 and 15 
(D6740) and pontic - porcelain/ceramic tooth # 14 (D6245) provided on December 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were advised the claims would be paid 
based on the date of service according to the plan benefit for the year the service took place. The Plan denied 
your request. The Plan says your benefit for the requested items or services $1,500 dollar limit was met. 
 
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 December 20, 2021.  
 
  
DATE OF SERVICE 
BEGINNING 
BALANCE 
TRANSACTION 
AMOUNT 
ENDING 
BALANCE 
June 21, 2021 $1500.00 $390.00  
December 20, 2021 $1100.00 $1100.00  
   $0 
 
Therefore, we decided that the Plan does not have to pay for a retainer crown - porcelain/ceramic tooth #'s 13 
and 15 (D6740) and pontic - porcelain/ceramic tooth # 14 (D6245) provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on April 21, 2022. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the services were 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 the subsequent nursing 
care provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on 
August 01, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you thought you had 
reached your out-of-pocket maximum. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B drugs. 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.You have been asked to pay $111.80 which is 20% of the allowed amount for 
the injections. At the time the claim was received you had not met your out-of-pocket maximum yet. Therefore, 
we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on August 
01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedure 
(D5899x2) and the extractions, erupted tooth requiring removal of bone (D7210x15) provided on August 10, 
2022. 
 
You asked the Plan to pay for the unspecified removable prosthodontic procedure (D5899x2) and the 
extractions, erupted tooth requiring removal of bone (D7210x15). You say that you were told the services were 
covered. You say you do not have the money to pay the bill. 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 
unspecified removable prosthodontic procedure (D5899x2) and the extractions, erupted tooth requiring 
removal of bone (D7210x15) provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 17, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denial. 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 May 19, 2022, and July 
28, 2022. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) 
provided on August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on June 30, 2022. 
 
You asked the Plan to pay for genetic testing. You say that this was medically necessary and should be 
covered. 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).there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for genetic testing provided on June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97813, 97814) provided on  
July 13, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as they were 
rendered by a non-covered provider type. 
  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97813, 
97814) provided on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) and a periodic oral evaluation (D0120) 
provided by an out-of-network provider August 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 16, 2022. 
Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) and a periodic oral 
evaluation (D0120) provided by an out-of-network provider August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 05, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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).there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on July 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on January 28, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that your policy says that eyeglasses can be bought 
anywhere. You say the claim was denied for being out-of-network. The Plan denied your request. The Plan 
says the provider was out-of-network. 
 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 you see any licensed vision provider in the United States. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyeglasses provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve harvest of bone for use in autogenous grafting 
procedure (D7295) for tooth number 18. 
 
You asked the Plan to pre-approve harvest of bone for use in autogenous grafting procedure (D7295) for tooth 
number 18. You say that you need an operation for your tooth because it was broken inside of your gums. The 
Plan denied your request. The Plan says this service is not covered under the member's benefit 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 pre-approve 
harvest of bone for use in autogenous grafting procedure (D7295) for tooth number 18.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on April 
09, 2022, to April 28, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you cannot afford this 
charge. 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 $350 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $350 copayment for inpatient hospital stay. This item/service falls within the 
Inpatient hospital 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.You have been asked to pay a total of $1,750 ($350 x 5 days) for your inpatient stay. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital stay provided 
on April 09, 2022, to April 28, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on June 30, 2022. 
 
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 that the services are not covered as billed. 
 
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. In this case, the Plan denied payment for services citing Medicare rules for 
unbundling laboratory services rendered during an inpatient stay. However, the Plan provided no evidence that 
the enrollee was registered as inpatient at the time the services took place. We only have what is presented to us 
in the case file, which states the enrollee's status at time of the specimen collection was outpatient. We find that 
the Plan has provided insufficient evidence to support the denial of payment for these services. Therefore, we 
decided that the Plan has to pay for the laboratory services provided on June 30, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network skilled nursing facility 
(SNF) provided from May 17, 2022, to May 27, 2022. 
 
You asked the Plan to waive the coinsurance for an out-of-network SNF. You say that you do not believe you 
should be charged for an out-of-network. 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% 
coinsurance for out-of-network skilled nursing facility (SNF) care.  
 
You have been asked to pay a 40% coinsurance for an out-of-network SNF. The total allowed amount for the 
SNF is 33,562.25 ($33,562.25 x 40% = $13,424.90). However, you are only being asked to pay $7,002.05 
which is less than the required amount. 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 an out-of-
network skilled nursing facility (SNF) provided from May 17, 2022, to May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on July 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says services could 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 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 wound care services provided on July 14, 2022, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on July 6, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy services. You say that the records provided support these 
services. The Plan denied your request. The Plan says there is no prior authorization on file and services can be 
obtained 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 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 physical therapy services provided on July 6, 
2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on August 08, 2021, to September 04, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. 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 $184 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $184 copayment for skilled nursing facility (SNF) care. This item/service falls 
within the 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.You have been asked to pay a $1,288 ($184 x 7 days) copayment for your 
SNF stay. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility 
(SNF) care provided on August 08, 2021, to September 04, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build-ups, including pins when required (D2950x2) 
on March 2, 2022. 
 
You asked the Plan to pay for the core build-ups, including pins when required (D2950x2). You say that you 
were not aware the services were not covered. 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 core 
build-ups, including pins when required (D2950x2) on March 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visit provided on June 30, 2022. 
 
You asked the Plan to pay for the home health visit. You say that medical records were submitted to support 
medical necessity. 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 home health visit 
provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
March 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware this provider was out-of-
network. 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 dental services provided by an out-of-network provider on March 30, 2022.