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

 
We decided that the Plan does not have to pay for the partial upper denture (D5213) and partial lower denture 
(D5214) provided on November 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told that this would be covered. The 
Plan denied your request. The Plan says partial dentures are not listed as 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, the partial dentures are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper 
denture (D5213) and partial lower denture (D5214) provided on November 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography angiography (CT 
angiography or CTA) scan provided on November 16, 2021. 
 
You asked the Plan to waive the copayment for CTA scan. You say that the Plan gave your provider a hard 
time about this scan and you are not paying this bill. The Plan denied your request. The Plan says the 
copayment amount you are being charged is correct. 
 
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 in-network CT scan provided by a provider other than the primary care provider.  
 
You have been asked to pay $275 copayment for CTA scan. CTA scan 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 a computed tomography angiography (CT angiography or CTA) scan provided on November 16, 2021.  
 
Your complaint about your experience with this health plan 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve vascular embolization and angiography services 
 
You asked the Plan to pre-approve the requested services. You say that the plan denied your request. The 
Plan says that the requested services are not applicable to the approved prostate artery embolization. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
The file shows that vascular embolization and angiographies of the abdomen, extremities, and viscera were 
requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our 
physician reviewer found that the enrollee has benign prostatic hyperplasia (BPH) and lower urinary tract 
symptoms. His international prostate symptom score (IPSS) is 18 on Tamsulosin and Finasteride. Prior 
treatment with Urolift and Rezume has produced moderate improvement. Prostate size is 58 gm. Vascular 
embolization and angiography services (abdominal, extremity, and visceral angiographies) are medically 
necessary as part of a prostate artery embolization. Prostate artery embolization involves angiography and 
embolization of the prostatic arteries. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve vascular embolization and angiography services  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) February 8, 2022. 
 
You asked the Plan to pay for the dental service. You say that this service should be covered. The Plan denied 
your request. The Plan says the claim denied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and a comprehensive oral evaluation is 
covered every 3 calendar years, the frequency limit has been exceeded. The record shows that the Plan paid for 
a comprehensive oral evaluation that you received on June 30, 2020. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150) February 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises, physical performance test or 
measurement, and therapeutic activities provided on July 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises, physical performance test or measurement, and therapeutic 
activities. You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
a prior authorization was not obtained by the out-of-network provider for the services rendered on July 23, 
2021. The Plan also says that the provider did not submit any documentation that the procedures were part of 
an emergency service. 
 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 therapeutic exercises, physical performance test or 
measurement, and therapeutic activities provided on July 23, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional amount for the panoramic x-ray (D0330) 
provided on December 21, 2021. 
 
You asked the Plan to reimburse an additional amount for the dental services. You say that you should have 
only been charged $64. You say that you received a refund check for $227.62. You say that you should be 
reimbursed an additional $139.88. The Plan denied your request. The Plan says 1 panoramic or complete series 
x-ray is covered every 36 months. The Plan also says that the frequency limit has been exceeded. 
 
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 and panoramic x-ray is listed as 
covered, the frequency limit has been exceeded. The record shows that the Plan paid for a complete series x-ray 
that you received on December 15, 2021. Therefore, we decided that the Plan does not have to reimburse an 
additional amount for the panoramic x-ray (D0330) provided on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an extremity study ultrasound and a 
specialist office visit provided on December 14, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound and a specialist office visit. You say that the 
provider's office told you the $25 was not due and now are receiving statements saying you owe the $25. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 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 carotid or peripheral vascular ultrasounds. The Plan contract also says that enrollees must pay a 
$20 copayment for a specialist office visit. The contract also says that a separate physician office copayment 
may apply if other services are rendered at the time of the visit.   
 
The record shows this claim is approved, and you have a cost sharing amount for both services. You have been 
asked to pay a $25 copayment for an ultrasound. An ultrasound falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. You have also been asked to pay a $20 copayment for a 
specialist office visit. You have been asked to pay a total of $45 ($25 copayment + $20 copayment = $45). A 
specialist office visit falls within the Physician/Practitioner Services, Including Doctors Office Visits 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 extremity study ultrasound and a specialist 
office visit provided on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing 
x-rays (D0274) provided on August 11, 2021, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you feel the claim should be paid. You say that 
the services are normally covered. You also say that you were not notified that the dentist was no longer in 
network. The Plan denied your request. The Plan says dental services received out of network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on August 11, 2021, by 
the out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound and specialist visit provided 
on January 7, 2022 
 
You asked the Plan to waive the copayment for an ultrasound and specialist visit. You say that this is the first 
time you've had 2 copayments in one doctor's visit. The Plan denied your request. The Plan says the copayment 
was applied 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 ultrasounds and a $20 copayment for specialist visits. You have been asked to pay a total of $45 for the ultrasound and specialist visit. An ultrasound falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. Specialist visits fall within 
the Physician/Practitioner services, including doctors office visits 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 the ultrasound and specialist visit provided on January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3 crowns, 2 pontics, and 2 unspecified adjunctive 
procedures provided from March 11, 2019, to April 2, 2019, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says dental services received out of network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the 3 crowns, 2 pontics, and 2 unspecified adjunctive procedures provided from March 11, 2019, to April 2, 
2019, by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0150), cleaning (D1110), panoramic x-
ray (D0330), fillings (D2391, D2392), and crown (D2740) provided from November 9, 2021, to December 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out of 
network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also 
says dental services received out of network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the oral evaluation (D0150), cleaning (D1110), panoramic x-ray (D0330), fillings (D2391, D2392), and crown 
(D2740) provided from November 9, 2021, to December 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck 
provided on December 15, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that necessary imaging from an in-
network provider should be a $0 copayment. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 
copayment for diagnostic procedures and tests, including ultrasounds.  
 
You have been asked to pay a $75 copayment for the ultrasound. The ultrasound 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 an ultrasound of the head and neck provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seat elevator (CPT code E2300), expandable controller 
(E2377), expandable controller harness (E2313), and electronic connection (E2311). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The seat elevator (E2300) does not 
serve a primary medical purpose and is statutorily non-covered. Electronic connection (E2311), expandable 
controller (E2377) and expandable controller harness (E2313) cannot be covered as it is not medically 
necessary to control the three approved power options through the joystick (drive interface). Therefore, we 
decided that the Plan does not have to pre-approve seat elevator (CPT code E2300), expandable controller 
(E2377), expandable controller harness (E2313), and electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network 
(OON) provider on November 15, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  
November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shank foot system (L5987) and an axial rotation unit 
(L5984) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a shank foot system and an axial rotation unit. You say that the requested 
items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 
for out-of-network care have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a shank foot system (L5987) and an axial rotation unit (L5984) to be provided by an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays of the chest provided on January 5, 
2022. 
 
You asked the Plan to waive the copayment for the X-rays. You say that you were told it would be covered. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for basic radiological services at an outpatient hospital, including X-rays.  
 You have been asked to pay $99.92, which is less than the $100 copayment for the X-rays. The X-rays fall 
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 X-rays of the chest provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), retainer 
crowns (D6740 x 2) and pontic (D6245) provided on October 7, 2021, and November 16, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you were never advised the provider 
was out of network. You also say that you are angry because you have to change to providers that do not know 
your history. The Plan denied your request. The Plan says the claim denied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation, retainer 
crowns, and pontic are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to reimburse you for the limited oral evaluation (D0140), retainer crowns (D6740 x 2) and pontic 
(D6245) provided on October 7, 2021, and November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057), and abutment 
supported crown (D6061) provided on January 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that crowns are covered once per tooth every 60 
months. You say that there is nothing in the benefit booklet to differentiate between different crowns. You also 
say that you are on a fixed income. The Plan denied your request. The Plan says the services were denied 
correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the custom fabricated abutment and 
abutment supported crown are not among those covered under this benefit. The record shows that the covered 
crowns referenced in the Evidence of Coverage are listed under restorative services. The services received in 
this case are implant service, not restorative. Therefore, we decided that the Plan does not have to pay for the 
custom fabricated abutment (D6057), and abutment supported crown (D6061) provided on January 4, 2022.