Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 
11, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you left the ER before having 
anything done, therefore you should not need to pay a copayment. The Plan denied your request. The Plan says 
the copayment applied was correct, due to medical records forwarded from the ER. 
 
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 $120 
copayment for emergency services.  
 
You have been asked to pay a $120 copayment for an ER visit. An ER visit falls within the Emergency 
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 waive the copayment for an emergency room visit 
provided on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for observation services on January 13, 2022. 
 
You asked the Plan to waive the coinsurance for observation services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing 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 a 50% 
coinsurance for outpatient hospital observation services. Observation services are hospital outpatient services 
given to determine if you need to be admitted as an inpatient or can be discharged. For outpatient hospital 
observation services to be covered, they must meet the Medicare criteria and be considered reasonable and 
necessary. Observation services are covered only when provided by the order of a physician or another 
individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or order 
outpatient tests. The provider billed in the amount of $315 and the allowed amount is $73.94. $73.94 x 50% = 
$36.97. Therefore, results in the total cost sharing amount of $36.97. 
 
 You have been asked to pay a 50% coinsurance for observation services. Observation services fall within the 
Outpatient hospital observation 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 
observation services on January 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient observation provided on 
January 12, 2022. 
 
You asked the Plan to waive the coinsurance for an outpatient observation. You say that the provider only 
checked on you once and you feel you should not have to pay your coinsurance due to this fact. The Plan 
denied your request. The Plan says the coinsurance 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 50% 
coinsurance for an out-of-network outpatient hospital observation. The allowed amount of this item is $138.53, 
resulting in a coinsurance amount of $69.26 ($138.53 x 50% = $69.26). 
 
You have been asked to pay a $69.26 coinsurance for an outpatient observation. An outpatient observation falls 
within the Outpatient Hospital Observation 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 outpatient observation provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist telehealth visits provided from 
February 9, 2022, to February 16, 2022. 
 
You asked the Plan to waive the copayments for the specialist telehealth visits. You say that you are on a fixed 
income and cannot afford the copayments. 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 $45 
copayment for each specialist visit, including telehealth services.  
 
You have been asked to pay a $45 copayment for each of the specialist telehealth visits, for a total of $90. The 
specialist telehealth visits fall 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 copayments for specialist telehealth visits 
provided from February 9, 2022, to February 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the computed tomographic angiography 
(CTA) scan of blood vessels in the neck with contrast provided on May 19, 2022. 
 
You asked the Plan to waive the cost share for the CTA scan. You say that money is tight, and you are 
dissatisfied with the amount you owe. 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 20% 
coinsurance for diagnostic radiology services.  
 
You have been asked to pay a 20% coinsurance for the CTA scan for a total of $84.22 ($421.11 allowed 
amount x 20% coinsurance = $84.22). The 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 cost share for the computed tomographic angiography (CTA) scan of blood vessels in the neck with contrast provided on May 
19, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
January 23, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel the enrollee 
should not be responsible for this cost share amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says the enrollee received ambulance services on January 23, 2022. 
The Plan says the correct copayment has applied per the enrollee's contract with the Plan. 
 
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 Ambulance Services.  
 
The enrollee has been asked to pay a $350 copayment for the ambulance services. The ambulance services fall within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with their Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay when they enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the ambulance services provided on January 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection provided on January 10, 2022. 
 
You asked the Plan to waive the copayment for the injection. You say that you have no copays for office visits 
based on your Medicare plan. 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 $295 
copayment for services provided at an outpatient hospital.  
 
You have been asked to pay the allowed amount of $248.58, which is less than the applicable copayment 
amount for the injection. The injection falls within the Outpatient Surgery and Other Medical 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 the injection provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a labial veneer on tooth #9 (D2960) provided on May 2, 
2022. 
 
You asked the Plan to pay for a veneer. You say that this service was medically necessary. The Plan denied 
your request. The Plan says a labial veneer (D2960) is not covered by your routine dental 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 a labial 
veneer on tooth #9 (D2960) provided on May 2, 2022.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve six physical therapy visits. We also decided that the Plan does not 
have to pre-approve three physical therapy visits.  
 
You asked the Plan to pre-approve therapy visits. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that additional physical therapy is not medically necessary. 
 
We decided that the Plan has pre-approve six physical therapy visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
the coverage criteria has been met for six physical therapy visits. Our physician reviewer found that the 
enrollee appears to require continued gait training and the unique skills of a professional therapist. Therefore, 
an additional six sessions of physical therapy are considered appropriate for further therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of six physical therapy visits have been met. Therefore, we decided that the Plan 
has to pre-approve six physical therapy visits.  
 
 We also decided that the Plan does not have to pre-approve three physical therapy visits. 
 
Our reviewer says that three physical therapy visits are not necessary to restore or maintain function or to 
prevent deterioration of the enrollee's condition. Our physician reviewer found that the most recent 
documentation indicated that the enrollee had improved functionally in terms of their Tinetti gait, balance 
assessment, timed get up, and go trials. However, there is no therapy re-revaluation provided to document his 
overall progress. 
 
Based on this information, we decided that Medicare rules for coverage of three physical therapy visits have 
not been met. Therefore, we decided that the Plan does not have to pre-approve three physical therapy visits.  
 
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 panoramic radiographic images (D0330) and a 
comprehensive oral evaluation (D0150), provided by a participating provider on January 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that all of these services have been dragged out. 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 D0330 was exhausted on date of service January 29, 2021, and D0150 was exhausted on 
March 29, 2021. Therefore, we decided that the Plan does not have to pay for panoramic radiographic images (D0330) and a comprehensive oral evaluation (D0150), provided by a participating provider on January 31, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-intravenous conscious sedation (D9248) and 
excision of hyperplastic tissue - per arch (D7970). 
 
You asked the Plan to pre-approve the sedation and excision. You say that your dentist said if you do not have 
these services done your gum issue will continue to happen. The Plan denied your request. The Plan says these 
services are not covered under your dental 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 non-
intravenous conscious sedation (D9248) and excision of hyperplastic tissue - per arch (D7970).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and panoramic 
radiographic image (D0330) provided on March 18, 2022. 
 
 
You asked the Plan to pay for the dental services. You say that you were not informed these procedures had 
frequency limitations. 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 both the comprehensive oral evaluation and panoramic radiographic image was 
exhausted on date of service July 30, 2021. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150) and panoramic radiographic image (D0330) provided on March 18, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant placements (D6010) for tooth #4, #6, #11, 
and #14. 
 
You asked the Plan to pre-approve the implant placements. You say that you were told that this service was 
covered. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because dental implants are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
implant placements (D6010) for tooth #4, #6, #11, and #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain fused to predominantly base metal crown for 
tooth 30 (D2751). 
 
You asked the Plan to pre-approve a porcelain fused to predominantly base metal crown for tooth 30 (D2751). 
You say that you are appealing with supporting records. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 a porcelain 
fused to predominantly base metal crown for tooth 30 (D2751) 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 a porcelain fused to predominantly base 
metal crown for tooth 30 (D2751). Our reviewer says that this does not meet criteria. Our physician reviewer 
found that given the appearance of the molar on the provided x-rays, it does not appeal to be reasonable and 
necessary due to the proximity of the existing restorations to the bone level. Our physician reviewer also found that given the appearance of tooth on the provided x-rays, there would be no reasonable method to get an 
appropriate crown margin in the furcation area of tooth number 30, and therefore the criteria has not been met. 
 
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 a porcelain fused to predominantly base metal crown for tooth 30 (D2751) have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to 
predominantly base metal crown for tooth 30 (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions of an erupted tooth or exposed root  
(D7140), the surgical placement of an implant body: endosteal implant (D6010), the interim implant abutment 
placements (D6051), and the intravenous moderate (conscious) sedation/analgesiaeach subsequent 15 minute 
increment (D9243) provided on April 22, 2021 and April 27, 2021. 
 
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 the services at issue are not payable as the 
claim was filed untimely. 
 
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 the dental services provided was not filed until May 15, 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 the extractions of an erupted tooth or exposed root (D7140), the 
surgical placement of an implant body: endosteal implant (D6010), the interim implant abutment placements 
(D6051), and the intravenous moderate (conscious) sedation/analgesiaeach subsequent 15 minute increment 
(D9243) provided on April 22, 2021 and April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that the only reason you got this plan is that 
you were advised that dentures would be covered. The Plan denied your request. The Plan says the requested 
partial dentures are not listed as covered dental items. 
 
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 partial dentures are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial upper denture (D5213) and partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330), complete series of radiographic 
imaging (D0210), and a comprehensive oral evaluation (D0150), provided by a participating provider on 
November 2, 2021. 
 
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 July 30, 2020. Therefore, 
we decided that the Plan does not have to pay for panoramic imaging (D0330), complete series of radiographic 
imaging (D0210), and a comprehensive oral evaluation (D0150), provided by a participating provider on 
November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns (D2740) and core buildup (D2950) on tooth 
#28 and #29. 
 
You asked the Plan to pre-approve the crowns and core buildup. You say that you need this service done 
because you cannot chew properly. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because crowns and core buildup are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
crowns (D2740) and core buildup (D2950) on tooth #28 and #29.