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

 
We decided that the Plan does not have to pay for the refraction, the eye exam, the visual field exam, the 
ophthalmic ultrasound, the ophthalmic diagnostic imaging, the medical eye exam, and the fundus photography 
provided from January 17, 2022, to February 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vision services. You say that the doctor's office did not check your primary 
doctor when making the approval. The Plan denied your request. The Plan says the provider was out-of-
network. 
 
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 did not pre-approve the 
vision services. We found no exception that would require the Plan to pay for the vision services. Therefore, we 
decided that the Plan does not have to pay for the refraction, the eye exam, the visual field exam, the 
ophthalmic ultrasound, the ophthalmic diagnostic imaging, the medical eye exam, and the fundus photography 
provided from January 17, 2022, to February 23, 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 domiciliary or rest home visit provided on December 06, 
2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the records provided support 
medical necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the domiciliary or rest 
home visit provided on December 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), intraoral-periapical 
first radiographic image (D0220), intraoral-periapical additional radiographic image (D0230), bitewing x-rays 
(D0274), dental cleaning (D1110), and the topical application of fluoride varnish (D1206) rendered by the out-
of-network (OON) provider on August 18, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), intraoral-periapical first radiographic image 
(D0220), intraoral-periapical additional radiographic image (D0230), bitewing x-rays (D0274), dental cleaning 
(D1110), and the topical application of fluoride varnish (D1206) rendered by the out-of-network (OON) 
provider on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and incisional biopsy of oral tissue 
(D0140, D7286) provided on November 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the limited oral evaluation has 
already been exhausted. Coverage for the incisional biopsy of oral tissue denied correctly as the services do not 
fall within your 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 27, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation and incisional biopsy of 
oral tissue (D0140, D7286) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a cleaning (D1110) provided by an out-of-network 
provider on November 10, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you are appealing the dental service. 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 cleaning (D1110) provided by an out-of-
network provider on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) provided on November 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told that you could not receive 
these services again. 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 September 28, 2021. 
Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0210) provided on November 
9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on October 14, 2021. 
 
You asked the Plan to pay more for the dental services. You say that your dental allowance is $1,800, so why 
was so little paid. 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. This benefit includes a non-
medical covered dental services allowance: Plan pays up to $1,000, every year for non-Medicare covered 
preventive dental services and non-Medicare covered comprehensive dental services combined. You are 
responsible for any amount above the dental coverage limit. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan paid 
$1,000 for services on October 14, 2021, which is the annual maximum. The record shows your benefit for the 
requested item or service was exhausted on date of service October 14, 2021. Therefore, we decided that the 
Plan does not have to pay more for dental services provided on October 14, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on July 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a decision 
within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, we find that the Plan has not provided enough evidence to support 
the denial of payment for the laboratory services based on Medicare criteria. The file shows that medical 
records were submitted; however, the Plan did not provide these for review. Therefore, we decided that the 
Plan has to pay for the laboratory services provided on July 1, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 12, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 10, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on January 25, 2022, to July 27, 
2022. 
 
You asked the Plan to pay for the office visits. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visits provided 
on January 25, 2022, to July 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for PT services provided on August 16, 2021, 
and August 30, 2021. 
 
You asked the Plan to waive the cost share for PT services. You say that your deductible had been met and you 
should not owe anything for the PT visits. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to PT services, 4% coinsurance for PT 
services, and a $1,200 out-of-pocket maximum.  
 
The item or service you asked the Plan to waive the cost share for falls within the PT services benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which 
applies to PT services. This cost sharing and the maximum out-of-pocket are contractual obligations that had 
not been met at the time PT services were received on August 16, 2021, to August 30, 2021. When the 
deductible was met with the processing of this claim, you were charged 4% coinsurance. Therefore, we decided 
that the Plan does not have to waive the cost share for PT services provided on August 16, 2021, and August 
30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), a complete 
series of radiographic images (D0210), and prophylaxis (D1110), provided on December 5, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with these charges. 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 for D0210 and D1110. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Your benefit for D0150 was exhausted on December 8, 2022. The Plan processed date of 
service December 8, 2022, prior to December 5, 2022. Therefore, we decided that the Plan does not have to pay 
more for a comprehensive oral evaluation (D0150), a complete series of radiographic images (D0210), and 
prophylaxis (D1110), provided on December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) 
provided on November 29, 2022. 
 
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 this 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-
complete series of radiographic images (D0210) provided on November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5226) provided on April 28, 2022. 
 
You asked the Plan to pay for dental services. You say that you are appealing the denial of services; the 
enrollee would not have received treatment if it was not covered. The Plan denied your request. The Plan says 
this service is not covered under your 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. Mandibular partial denture - 
flexible base (including retentive/clasping materials, rests, and teeth) (D5226) is not covered under the Plans 
dental benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5226 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for mandibular 
partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5226) provided on 
April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the retreatment of a root canal (D3347) for tooth #12 
provided by an out-of-network provider on September 19, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you would like the Plan to cover the 
retreatment of the root canal and you are concerned about future dental services you may need. 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 the retreatment of a root canal (D3347) for 
tooth #12 provided by an out-of-network provider on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) provided on July 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your $1,000 annual dental benefit 
maximum allowance 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 28, 2022. Therefore, 
we decided that the Plan does not have to pay more for a crown (D2740) provided on July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing aids (V5261 x 2) purchased on 
October 5, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 $899 
copayment for a premium hearing aid from the Plans select hearing aid provider.  
 
You have been asked to pay $1,798 ($899 copayment x 2) for the premium hearing aids purchased in this case. 
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 hearing aids (V5261 x 2) purchased on 
October 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on October 7, 
2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for this service is included in payment to the hospital. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes A0428, & A0425 is not supported in the medical record. Specifically, the enrollee was 
an inpatient at the time this service was provided. Payment for transportation is included in payment to the 
hospital. Based on this information, we decided that Medicare rules for coverage of the ambulance services 
have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0428, 
A0425) provided on October 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 
03, 2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for ambulance services. This item/service falls within the 
ambulance 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 ambulance services 
provided on January 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on October 25, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that there are no Plan outlines at the living 
facility, so we cannot verify each visit for each patient. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on October 25, 2022.