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

 
We decided that the Plan does not have to waive the coinsurance for the aminolevulinic acid injection provided 
on January 5, 2023. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were told that you would only 
have the $45 copayment for this service. 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 in or out-of-network Medicare Part B drugs.  
 
You have been asked to pay $78.12, which is 20% coinsurance of the allowed amount for the aminolevulinic 
acid injection ($390.60 allowed amount x 20% coinsurance = $78.12). This item/service falls within the 
Medicare Part B 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 the 
aminolevulinic acid injection provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction, of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210) provided on November 15, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 extraction, of an erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210) provided on November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), and 
intraoral - periapical first radiographic image D0220) provided on October 27, 2022. 
 
You asked the Plan to pay for limited oral evaluation - problem focused (D0140), and intraoral - periapical first 
radiographic image D0220). You say that this was an emergency as you had a cracked tooth with a fractured 
root. The Plan denied your request. The Plan says these services are not covered under the benefit package. 
 
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 limited 
oral evaluation - problem focused (D0140), and intraoral - periapical first radiographic image D0220) provided 
on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), and panoramic radiographic image (D0330) provided on December 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you switched dentists. You also say that the new 
dentist had to do a comprehensive oral evaluation and panoramic x-rays. 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 30, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150), and panoramic radiographic image (D0330) provided on December 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 24,  2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
not be responsible for this bill because you did not call the ambulance. You also say that you wife drove you to 
the hospital. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 24, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on September 24,  2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skin removal procedure provided on June 22, 2022. 
 
You asked the Plan to pay for a skin removal procedure. You say that this was medically necessary and should 
be covered. 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 skin removal 
procedure provided on June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network eye muscle repair procedure 
provided on October 18, 2022. 
 
You asked the Plan to waive the copayment for an in-network eye muscle repair procedure. You say that you 
are very  disappointed with this surgery and provider. The issue was not resolved and would like the $350 
copayment back. 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 for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay a $350 copayment for an in-network eye muscle repair procedure. This 
item/service 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 an in-network eye muscle repair procedure provided on October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), 
intraoral-periapical first radiographic image (D0220), and the porcelain/ceramic crown (D2740) provided on 
December 20, 2021 and December 22, 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 these services are not payable as the provider 
is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the limited 
oral evaluation-problem focused (D0140), intraoral-periapical first radiographic image (D0220), and the 
porcelain/ceramic crown (D2740) provided on December 20, 2021 and December 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered ambulance mileage (A0888) provided on 
September 26, 2022. 
 
You asked the Plan to pay for ambulance mileage. The Plan denied your request. The Plan says this charge is 
not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that miles beyond the closest available facility, billed with 
code A0888, are not covered by Medicare. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
ambulance mileage. have not been met. Therefore, we decided that the Plan does not have to pay for non-covered 
ambulance mileage (A0888) provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, of a molar tooth (excluding final 
restoration) (D3330) provided on December 20, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental service was received from an out-
of-network provider and is 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 dental service from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the service provided is 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 the 
endodontic therapy, of a molar tooth (excluding final restoration) (D3330) provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on December 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel the services should all be 
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. This benefit includes $1,000 
combined allowance for supplemental preventive and comprehensive dental services every year. Enrollee is 
responsible for 100% of charges beyond the $1,000 allowance or if you exceed a service limit. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit of $1,000 was exhausted on date of service December 20, 2022. The Plan paid $122.50 for 
date of service January 4, 2022, paid $89.50 for date of service September 26, 2022, paid $133.50 for date of 
service December 6, 2022, and paid $654.50 for date of service December 20, 2022 ($122.50 + $89.50 + 
$133.50 + $654.50 = $1,000). Therefore, we decided that the Plan does not have to pay more for dental 
services provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial denture - flexible base (D5226) provided 
on August 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you think the service you received should be 
covered by your insurance. 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 the 
requested mandibular partial denture - flexible base (D5226) but is limited to one procedure every five plan 
years 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested D5226 was exhausted on date of service June 6, 2019. Therefore, we 
decided that the Plan does not have to pay for mandibular partial denture - flexible base (D5226) provided on 
August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950), pontics (D6245), and retainer crowns 
(D6740) for tooth #2, #3, #4, #5, and #6 provided on September 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to refund you money 
for services that are covered in your policy. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because the core buildup, pontics, and retainer crowns 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 pay for core 
buildup (D2950), pontics (D6245), and retainer crowns (D6740) for tooth #2, #3, #4, #5, and #6 provided on 
September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each specialist office visit provided on July 
13, 2022, to August 26, 2022. 
 
You asked the Plan to waive the copayment for each specialist office visit. You say that you shoulld not have to 
pay because you did not get the services you wanted. 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 in-person physician/pracitioner services. 
 
You have been asked to pay a $35 copayment for each specialist office visit. This item/service falls within the 
in-person physician/pracitioner 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 each specialist office visit provided on July 13, 2022, to August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for labratory services provided on September 20, 2022. 
 
You asked the Plan to pay for labratory services. You say that this was medically necessary and should be 
covered. 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 labratory services 
provided on September 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network dermatological procedure 
provided on September 08, 2022. 
 
You asked the Plan to waive the coinsurance for an in-network dermatological procedure. You say that these 
numbers seem very high, you wanted to be sure they were correct. 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 services obtained from a specialist, or under certain circumstances. 
 
You have been asked to pay 20% coinsurance for an in-network dermatological procedure. This item/service 
falls within the services obtained from a specialist, or under certain circumstances 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. The allowed amount is $2,238.97 x 
20% coinsurance = $447.80 total for the procedure. Therefore, we decided that the Plan does not have to waive 
the coinsurance for an in-network dermatological procedure provided on September 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin- based composite- one surface, posterior (fillings)) 
(D2391) provided on October 18, 2022. 
 
You asked the Plan to pay for dental services. You say that you had the filling because you thought this was 
covered under your insurance. The Plan denied your request. The Plan says your dental plan does not show you 
have the optional benefit that covers comprehensive dental services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for resin- based composite- one 
surface, posterior (fillings)) (D2391) provided on October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM), supplies and 
accessories provided on September 16, 2022. 
 
You asked the Plan to pay for the CGM, supplies and accessories. The Plan denied your request. The Plan says 
the enrollee does not require insulin three or more times daily. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM, supplies and accessories. have not been met. Therefore, we decided that the Plan does not have to 
pay for a continuous glucose monitor (CGM), supplies and accessories provided on September 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on September 09, 
2021. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that this was medically necessary and 
should be covered. 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 skilled nursing facility 
visit provided on September 09, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS heart monitor device. 
 
You asked the Plan to pre-approve CardioMEMS heart monitor device. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 CardioMEMS heart monitor device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has congestive heart failure. There is lack of clinical and 
scientific evidence of meaningful benefit. Therefore, the enrollee does not meet criteria for the requested 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS heart monitor device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve CardioMEMS heart monitor device.