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

 
We decided that the Plan does not have to reduce the coinsurance for prophylaxis (D1110), bitewing x-rays 
(D0272), periapical x-rays (D0230, D0220), a periodic oral evaluation (D0120), and a partial mandibular 
denture (D5212) provided on February 23, 2022. 
 You asked the Plan to reduce the coinsurance for the dental services. You say that you were told the provider 
was in-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 enrollees have a $50 
deductible for basic and major dental services. The contract says that you have 30% coinsurance for out-of-
network prophylaxis, dental x-rays, and an evaluation. The contract also says that you have 70% coinsurance 
for an out-of-network partial mandibular denture. 
 
You have been asked to pay a total of $715.50 for the dental services received on February 23, 2022. These 
items/services fall within the dental services benefit category.  
 
Code Allowed Amount Deductible Coinsurance 
D1110 $95  $28.50 
D0272 $30  $9 
D0230 $15  $4.50 
D0220 $20  $6 
D0120 $75  $22.50 
D5212 $900 $50 $595 
Total  $715.50 
 
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 reduce the coinsurance for prophylaxis (D1110), bitewing x-rays (D0272), periapical 
x-rays (D0230, D0220), a periodic oral evaluation (D0120), and a partial mandibular denture (D5212) provided 
on February 23, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on March 10, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the transport took place before the 
enrollee's hospice election. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The hospice 
benefit covers the date of election and is not time specific. Therefore, we decided that the Plan does not have to 
pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage 
(A0425) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral x-rays (D0210), 
and prophylaxis (D1110) provided on May 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 periodic oral evaluation (D0120), intraoral x-rays (D0210), and prophylaxis (D1110) provided on 
May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a cane on March 3, 2022. 
 
You asked the Plan to waive the coinsurance for a cane. You say that you would like to appeal 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 20% 
coinsurance for a cane.  
 
You have been asked to pay a 20% coinsurance for a cane. This item/service falls within the Durable medical 
equipment (DME) and related 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 coinsurance 
for a cane on March 3, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI. 
 
You asked the Plan to pre-approve an MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that that medical necessity cannot be determined without some kind of documentation 
discussing the member's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI. Our reviewer says that an MRI 
is medically reasonable and necessary. You were initially diagnosed with a space occupying lesion in the brain 
of indeterminate etiology. You had previously been hospitalized and at that time follow-up imaging was 
recommended post-discharge. In such a setting it is well within the standards of care to perform repeat imaging 
to evaluate for any changes in the mass/lesion. This would help with further attempts at classification and 
treatment planning/decision making. Our physician reviewer found that your condition meets criteria for 
coverage of an MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan has to pre-
approve an MRI.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 15, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on November 15, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for the clinical trial services provided from June 21, 
2021, to October 18, 2021. 
 
You asked the Plan to further pay for the services provided. You say that you were not made aware of your 
obligation. 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 will pay the same 
amount for services you receive as part of the study as you would if you received these services from the Plan.  
 
We looked at the file and the rules. The services fall within the outpatient diagnostic tests and physician 
services 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 further pay for the clinical trial services provided 
from June 21, 2021, to October 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of interlaminar/interspinous process 
stabilization/distraction device. 
 
You asked the Plan to pre-approve the implantation of interlaminar/interspinous process 
stabilization/distraction device. You say that this procedure is medically reasonable and necessary. The Plan 
denied your request. The Plan says the requested procedure is considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 implantation of 
interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found interspinous process distraction devices are experimental. More research is needed to show safety and 
efficacy before coverage can be approved. 
 
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 implantation of interlaminar/interspinous process stabilization/distraction 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of 
interlaminar/interspinous process stabilization/distraction device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 3 and 12. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has extensive decay on tooth # 
3 below the gumline. You also say that tooth # 12 has a fracture with decay which require a crown to restore. 
The Plan denied your request. The Plan says there is not significant breakdown to warrant a crown. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the crowns for teeth # 3 and 12 are not medically necessary. Our physician reviewer found the provided 
documentation does not show extensive structural breakdown such that a full coverage crown would be 
required. Therefore, the reviewer found that the requested crowns are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve crowns (D2740) for teeth # 3 and 12.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services and injection provided on February 
1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmology services. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
  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 ophthalmology services and injection provided on 
February 1, 2022, 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 radiological service on May 3, 2022. 
 
You asked the Plan to waive the copayment for radiological service. You say that you were told that the 
procedure would cost $0 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 $105 
copayment for basic radiological service.  
 
You have been asked to pay $105 copayment for radiological service. This item/service falls within the basic 
radiological service 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 radiological service 
on May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the patient did not have a card, and you did not know 
that a prior authorization was needed. The Plan denied your request. The Plan says the rendering provider is a 
non-participating provider. The Plan also says that they did not authorize any services for this 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 an office visit provided on June 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) provided on 
February 25, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the claim should be 
reprocessed and paid. The Plan denied your request. The Plan says the corrected claim was not received timely. 
 
The Plan follows Medicare rules. The rules say that a corrected claim must be submitted within 1 year from the 
date of initial determination or redetermination for any reason. 
 
The record shows that a corrected claim for the evaluation and management service was not filed until June 2, 
2022. This means that more than one calendar year from the date initial determination or redetermination for 
any reason. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit 
(G0463) provided on February 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a polysomnography provided on May 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a polysomnography. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 a polysomnography provided on May 28, 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 periodontal maintenance (D4910) provided on June 30, 
2022. 
 
You asked the Plan to pay for the dental services. You say that this service is covered. 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 10, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 nursing facility visit 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 magnetic resonance imaging (MRIs) 
provided on May 2, 2022, and May 19, 2022. 
 
You asked the Plan to waive the copayment for MRIs. You say that both of these copayments are too high, you 
should only have a specialist 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 $180 
copayment for outpatient diagnostic tests and therapeutic services and supplies ($180 x 2 visits = $360).  
 
You have been asked to pay a $360 copayment for MRIs. 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 magnetic resonance imaging (MRIs) provided on May 2, 
2022, and May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the wound care and the cast application 
provided from April 20, 2022, to June 21, 2022. 
 
You asked the Plan to reduce the copayments for the wound care and the cast application. You say that you 
should only be responsible to pay a $45 copayment each time. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
 
 
 
  You have been asked to pay $2,238.78 for the wound care and the cast application.  
 
Date of Service Service Plan Allowance Cost Per Contract Your Responsibility 
April 20, 2022 Wound Debridement $342.11 $250 $250 
April 26, 2022 Wound Debridement $342.11 $250 $250 
April 28, 2022 Cast Application $238.78 $250 $238.78 
May 4, 2022 Wound Debridement $342.11 $250 $250 
May 10, 2022 Wound Debridement $342.11 $250 $250 
May 19, 2022 Wound Debridement $342.11 $250 $250 
May 26, 2022 Wound Debridement $342.11 $250 $250 
June 8, 2022 Wound Debridement $342.11 $250 $250 
June 14, 2022 Wound Debridement $342.11 $250 $250 
TOTAL    $2,238.78 
 
These items/services fall within outpatient hospital facility 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 reduce the copayments for the wound care and the cast application provided from April 20, 2022, to June 21, 
2022.