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

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) and drugs or 
medicaments (D9630 x 2) provided from March 22, 2022, to March 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that there was no anesthesia provided at either visit. 
You also say that your copayment was only supposed to be $25, not $36.80. The Plan denied your request. The 
Plan says that gingival irrigation and drugs or medicaments are not listed as covered services.  
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 gingival irrigation and drugs or 
medicaments are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the gingival irrigation (D4921 x 2) and drugs or medicaments (D9630 x 2) provided from March 22, 
2022, to March 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided April 28, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you did not need transport to the hospital. 
The Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
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 April 28, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met.  Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided April 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 10, 
2021. 
 
You asked the Plan to pay for the nursing facility care. You say that this medically necessary service was 
provided in good faith. The Plan denied your request. The Plan says original Medicare is responsible for 
payment.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care provided on August 10, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic services provided on June 3, 
2021. 
 You asked the Plan to waive the copayment for chiropractic services. You say that you are on a fixed income 
and cannot afford the copayment. The Plan denied your request. The Plan says the copayment 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 $15 
copayment for each in-network Medicare-covered chiropractic visit.  
 
You have been asked to pay $15 for the chiropractic services. Chiropractic services fall within the Chiropractic 
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 chiropractic services 
provided on June 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from December 14, 2021, to December 16, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you had this surgery before and never 
received a bill. You say that you do not understand why the services were not covered. The Plan denied your 
request. The Plan says the drugs you received in the outpatient setting are considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B. 
 
 
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 in an outpatient setting from December 14, 2021, to December 16, 2021.  
 
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 dental services (D0210, D0150, D4342) provided by an out-
of-network provider on April 25, 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 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 Plan's 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 dental services (D0210, D0150, D4342) provided by an out-of-network provider on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the intravenous infusion services 
provided from December 13, 2021, to December 17, 2021. 
 
You asked the Plan to reduce the cost sharing for the infusion services. You say that you are questioning your 
chemotherapy copays. You would like an explanation on the copay amounts. 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 $370 
copayment for services provided at an outpatient hospital facility. Since the allowed amount is less than the 
copayment you have been asked to pay this amount, which is $194.25 per visit ($194.25 per visit x 5 visits = 
$971.25). 
 
You have been asked to pay the allowed amount of $971.25, which is less than combined copayments of $1850 
for services provided at an outpatient hospital facility. Infusion services fall 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 reduce the cost sharing for the intravenous infusion services provided 
from December 13, 2021, to December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the facility should have obtained the prior 
authorization. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 3, 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 an office visit provided on January 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 25, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7210) provided on May 20, 2022. 
 
You asked the Plan to pay for an extraction. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a surgical extraction (D7210) is not covered by 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, 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 surgical 
extraction (D7210) provided on May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on November 8, 
2021. 
 
You asked the Plan to pay for periodontal maintenance. You say that this cleaning should be covered. The Plan 
denied your request. The Plan says periodontal maintenance (D4910) is not covered by your supplemental 
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 
periodontal maintenance (D4910) provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and intraoral - complete series of radiographic images (D0210) provided April 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you didn't receive a cleaning and the office 
insisted on doing their own exam and cleaning. 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 April 29, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided April 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $15 copayment for the chiropractic service provided on 
June 8, 2021. 
 
You asked the Plan to waive the $15 copayment for the chiropractic service. You say that you were told the 
provider was in network and if you would have known you never would have gone to the appointment. The 
Plan denied your request. The Plan says the $25 copayment for therapy services was waived and the $15 
copayment applied correctly to the chiropractic service. 
 
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 $15 
copayment for each in-network Medicare covered chiropractor visit and a $55 copayment for each out-of-
network Medicare covered chiropractor visit.  You have been asked to pay the in-network $15 copayment for the chiropractic service. Chiropractic care falls within the Chiropractic 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 $15 copayment 
for the chiropractic service provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), topical application of fluoride varnish (D1206), and scaling in presence of 
generalized moderate or severe gingival inflammation (D4346) provided on April 7, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the dental services. You say that no communication was provided notifying your 
office that the treating provider was OON. 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 the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), topical 
application of fluoride varnish (D1206), and scaling in presence of generalized moderate or severe gingival 
inflammation (D4346) provided on April 7, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) provided 
by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve these 
services. 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 15, 2021. Therefore, 
we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) provided 
by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance provided on April 22, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you did not receive periodontal 
maintenance. The Plan denied your request. The Plan says the periodontal maintenance is not a covered 
service. 
 
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. The provider sent a letter stating they performed periodontal 
maintenance. This service is not a covered benefit under your plan. Therefore, we decided that the Plan does 
not have to pay for periodontal maintenance provided on April 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a pacemaker pulse generator procedure 
provided on April 19, 2022. 
 
You asked the Plan to waive the coinsurance for a pacemaker pulse generator procedure. You say that you 
cannot afford this coinsurance and would like it to be reconsidered. The Plan denied your request. The Plan 
says the coinsurance applied was 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 25% 
coinsurance for outpatient hospital observation. The allowed amount of this item is $22350.95 resulting in a 
coinsurance amount of $5587.74 ($22350.95 x 25% = $5587.74). 
 
You have been asked to pay a $5587.74 coinsurance for a pacemaker pulse generator procedure. A pacemaker 
pulse generator procedure 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 a pacemaker pulse generator procedure provided on April 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for fluoroscopic guidance for needle biopsy 
provided on February 8, 2022. 
 
You asked the Plan to waive the copayment for the fluoroscopic guidance. You say that the cost sharing 
amounts are inconsistent. 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 $115 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $115 copayment for the fluoroscopic guidance. The fluoroscopic guidance falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for fluoroscopic guidance for needle biopsy provided on February 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265) and the sinus augmentation with bone or bone substitutes (D7951) provided on 
September 10, 2021. 
 
You asked the Plan to pay for these items/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 items/services are not covered 
under your contractual policy. 
 
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 items and services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
biologic materials to aid in soft and osseous tissue regeneration, per site (D4265) and the sinus augmentation 
with bone or bone substitutes (D7951) provided on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth, completely bony (D7240 x 
2), and removal of impacted tooth, partially bony (D7230 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you need your wisdom teeth removed so 
you can get dentures. You say that it was your understanding that your insurance covered these services. The 
Plan denied your request. The Plan says removal of impacted tooth is not listed as a covered service. 
 
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 
removal of impacted tooth, completely bony (D7240 x 2), and removal of impacted tooth, partially bony 
(D7230 x 2).