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

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on October 
11, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. 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 $35 
copayment for Specialist office visits. 
 
You have been asked to pay a $35 copayment for specialist office visit. This item/service falls within the 
Specialist 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 specialist 
office visit provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for pain management on August 08, 2022. 
 
You asked the Plan to waive the coinsurance for pain management. You say that you want to appeal the 
amount being charged. 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% 
coinsurance for each Medicare-covered specialist office visit. Covered services include consultation, diagnosis, 
or any other location. The provider billed in the amount of $379 and the allowed amount is $184.85. $184.85 x 
50% = $92.43. Therefore, results in the total cost sharing amount of $92.43. 
 
You have been asked to pay a 50% coinsurance for pain management. This item/service falls within the 
Physician/practitioner services, including doctor's 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 coinsurance for pain management on August 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 21, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan changed the rules without notice. 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 June 28, 2022, and July 
13, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7140) provided on September 8, 
2022. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency extraction. 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 surgical extraction (D7140) provided on September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general health panel laboratory services provided on June 4, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for general health panel laboratory service. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says an authorization was not obtained prior to 
the services being rendered. 
 
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 general health panel laboratory services provided 
on June 4, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency department visit and 
observation, and an inpatient stay provided from August 20, 2022, to September 16, 2022. 
 
You asked the Plan to waive the copayments for an emergency department visit and observation, and an 
inpatient stay. You say that you cannot afford this, it was an emergency and you needed care. There are too 
many hidden fees. 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 per day, for days 1 to 7, for inpatient hospital care, and a $90 copayment for emergency care. You 
were in the hospital for 5 days, with a copayment of $250 per day, resulting in a $1250 total copayment ($250 x 
5 days = $1250). $1250 + $90 = $1340. You have been asked to pay a combined $1340 copayment for inpatient hospital care, and emergency care. 
This item/service falls within the inpatient hospital care, and emergency 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 copayments for an emergency department visit and observation, and an inpatient 
stay provided from August 20, 2022, to September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120), 
prophylaxis - adult (D1110), intraoral - periapical first radiographic image (D0220), and intraoral - periapical 
each additional radiographic image (D0230) provided on September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the reason for the services was to prepare for an 
upcoming surgery. You also say that you were required to have a cleaning within the last six months, have no 
current infections and no anticipation of any upcoming dental work. The Plan denied your request. The Plan 
says the denial is correct because these services are not covered by the Plan's dental benefits or they are 
covered but the coverage benefit has 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 
periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image 
(D0230) is not covered by your Plans dental benefits. The record shows your benefit for the periodic oral 
evaluation - established patient (D0120), and prophylaxis - adult (D1110) was exhausted on date of service 
January 12, 2022.  
 
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient 
(D0120), prophylaxis - adult (D1110), periapical first radiographic image (D0220), and intraoral - periapical 
each additional radiographic image (D0230) provided on September 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on August 25, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that the copayment is too high. 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 per visit at a hospital outpatient facility. The provider billed in the amount of $374 and the allowed 
amount is $204.67. This is less than the copayment amount. Therefore, results in the total cost sharing amount 
of $204.67. 
 
 
 
 
 
 You have been asked to pay a $204.67 copayment, which is less than for outpatient surgery. This item/service 
falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 outpatient surgery on 
August 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on October 13, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the provider saw it was fit to prescribe 
you Tylenol. You also say that being under the hospital's care, there was no way that you could have 
administered the medication to yourself, and you would like this to be refunded. The Plan denied your request. 
The Plan says self-administered drugs are not a covered benefit while under an outpatient hospital stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on October 13, 2022.  
 
  Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on September 
14, 2022. 
 
You asked the Plan to pay for a bone replacement graft. You say that a root canal was denied, so an implant 
was provided. The Plan denied your request. The Plan says the rendered dental 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 a bone 
replacement graft (D7953) provided on September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen compressor provided on April 
19, 2022. 
 
You asked the Plan to waive the coinsurance for an oxygen compressor. You say that this is a medical 
necessity and should be covered without a secondary 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this drug or 
item is $107.81, resulting in a coinsurance amount of $21.56 ($107.81 x 20 % = $21.56). 
 
You have been asked to pay a $21.56 coinsurance for an oxygen compressor. 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 an oxygen compressor provided on April 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for Medicare-covered Part B drugs and a 
specialist visit provided on March 30, 2022, and June 29, 2022. 
 
You asked the Plan to reduce the cost share for Medicare-covered Part B drugs and a specialist visit. You say 
that you are unable to afford the cost share for services rendered and the treatment did not work. 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 all drugs covered under Original Medicare and a $25 copayment for each specialist visit.  
 
 
  You have been asked to pay a total cost share of $1,113.64 for Medicare-covered Part B drugs and a specialist 
visit. This total includes a coinsurance of $1,088.64, which is 20% of the allowed amount for Medicare-
covered Part B drugs ($5,443.20 allowed x 20% = $1,088.64) and a $25 copayment for a specialist visit. 
Medicare-covered Part B drugs fall within the Medicare Part B prescription drugs benefit category. A specialist 
visit falls within the Physician/Practitioner services benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the 
cost share for Medicare-covered Part B drugs and a specialist visit provided on March 30, 2022, and June 29, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composite (D2394) and an amalgam 
(D2161) provided on September 7, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you believe the Plan should pay for this. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a resin-based composite (D2394) and an 
amalgam (D2161) provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), progressive lenses (V2781), anti-reflective 
coating (V2750), variable asphericity lens (V2410) provided on April 29, 2021. 
 
You asked the Plan to pay for frames (V2020), progressive lenses (V2781), anti-reflective coating (V2750), 
variable asphericity lens (V2410). You say that your policy states that $70 eyeglass allowance is given every 
two years. You also say you should have two years to submit the claim. The Plan denied your request. The Plan 
says the claim was submitted over 12 months past the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for frames (V2020), progressive lenses (V2781), anti-reflective coating (V2750), 
variable asphericity lens (V2410) was not filed until August 17, 2022. This means that more than one calendar 
year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not 
have to pay for frames (V2020), progressive lenses (V2781), anti-reflective coating (V2750), variable 
asphericity lens (V2410) provided on April 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on August 10, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount 
being charged. 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 all other drugs covered under Medicare Part B. Covered drugs include drugs that usually arent 
self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, 
or ambulatory surgical center services. The provider billed in the amount of $8,386.18 and the allowed amount 
is $1,458.85. $1,458.85 x 20% = $291.77. Therefore, results in the total cost sharing amount of $291.77. 
 
You have been asked to pay a 20% coinsurance for 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. Therefore, we decided that the Plan does not have to waive the coinsurance for Part B 
drugs on August 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan 
 
You asked the Plan to pre-approve the PET scan. You say that you are appealing the denied service. The Plan 
denied your request. The Plan says the criteria for Medicare coverage were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the PET scan have been met. There 
was no medical documentation provided. Therefore, we decided that the Plan does not have to pre-approve a 
positron emission tomography (PET) scan
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chronic care management services 
provided on August 31, 2022. 
 
You asked the Plan to waive the copayment for the chronic care management services. You say that you 
received a monitor that you did not use, and you feel you should not have to pay. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for physician/practitioner services, including doctors office visits (specialist). 
 
You have been asked to pay a $25 copayment for the chronic care management services. This item/service falls 
within the physician/practitioner services, including doctors office visits (specialist) 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 chronic care management services provided on August 
31, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on September 03, 2022. 
 
You asked the Plan to waive the copayment for ER visit. 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for ER visit. This item/service falls within the Emergency 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 ER visit provided on September 
03, 2022.