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

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and 
gingival flap procedure (D4241) provided on December 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have not used your dental insurance in 6 
years. You say that you were not aware that you had it. You also say that you feel these services should be 
covered since you have not used your dental benefit for 6 years. The Plan denied your request. The Plan says 
the claim denied correctly. 
 
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. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive periodontal 
evaluation and gingival flap procedure are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and gingival flap 
procedure (D4241) provided on December 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection provided on January 13, 
2022. 
 
You asked the Plan to waive the coinsurance for injection. You say that you've had injections before and have 
never had coinsurance. 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 20% 
coinsurance for intravenous, subcutaneous, and biological Part B drugs for the injection.  
 
You have been asked to pay a total of $1.14 for the injection. Injection falls within the Medicare Part B 
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the injection 
provided on January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 10 placements of intra-socket biological dressings 
(D7922 x10) provided on February 24, 2021. 
 
You asked the Plan to pay for the placements of intra-socket biological dressings. You say that you had to pay 
for this service out of your own pocket and were hoping Medicare could help refund some of the charges. The 
Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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. 
 
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 the 10 
placements of intra-socket biological dressings (D7922 x10) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that this should be covered because the doctor is listed 
as being in-network. 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 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 the office visit provided on November 9, 2021, 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 office visits provided on October 11, 2021, to November 
30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that you were not aware the provider was out-of-
network. 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visits provided on October 11, 2021, to 
November 30, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on December 10, 
2021. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you are being charged a second 
emergency room copayment. 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 $50 copayment for outpatient procedures, including an endoscopy. The Plan contract says that enrollees must pay a 
$0 copayment for outpatient hospital observation. The contract also says that if you have additional outpatient 
services while in observation, an additional cost share may apply. 
 
According to the EOC, additional cost sharing applies while being held in observation. The medical record 
shows you were in observation from December 8, 2021, to December 10, 2021. You have been asked to pay a 
$50 copayment for an endoscopy. An endoscopy falls within the Outpatient Surgery, Including Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an endoscopy provided on December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three gingival irrigations (D4921 x3). 
 
You asked the Plan to pre-approve the gingival irrigations. You say that the oral surgeon has requested gingival 
irrigations with extraction to remove the infection. You also say that you would like this service approved to 
prevent further complications. The Plan denied your request. The Plan says this service is not covered under 
your 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 pre-approve three 
gingival irrigations (D4921 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy provided on December 1, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy. You say that the enrollee was not aware of his Part C 
insurance. You say you were also not aware of his insurance. 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the physical therapy provided on December 1, 2021, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on December 27, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that at the time of service, the member 
was residing at the facility and therefore, the rendering provider was not responsible to obtain authorization. 
You also say that the assisted living facility is responsible to obtain prior authorization for all of their patients, 
which should also cover for the medical treatment provided by the rendering provider. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the services being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
December 27, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for manual therapy, electrical stimulation, and therapeutic 
procedures provided on August 11, 2021, by an out-of-network (OON) provider. 
 You asked the Plan to pay for manual therapy, electrical stimulation, and therapeutic procedures. You say that 
you do not understand why some dates of service and claims were paid, but not the other dates of services, 
which were all together. The Plan denied your request. The Plan says the rendering provider is a non-
participating provider, and the referring provider involved in these services is a non-participating provider with 
the Plan. The Plan also says that they did not authorize any services for this provider or the facility. 
 
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 manual therapy, electrical stimulation, and 
therapeutic procedures provided on August 11, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), panoramic x-ray (D0330), and 
bitewing x-rays (D0274) provided on January 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that your endocrinologist advised you to get a dental 
exam and restart general care so you can be cleared to receive the prescribed infusion. You say that you are 
working hard to located providers that are in network. The Plan denied your request. The Plan says the provider 
in this case is out of network. The Plan also says that dental services received out of network are not covered. 
 
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 and the services are listed as covered, 
dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), panoramic x-ray (D0330), and bitewing x-rays 
(D0274) provided on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visits provided from January 6, 
2021, to November 30, 2021. 
 
You asked the Plan to waive the copayment for the specialist visits. You say that you paid your original copays 
and took the refunds in good faith and you don't feel you should have to be penalized for someone's mistakes. 
The Plan denied your request. The Plan says the copayments 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 $25 for 
each covered visit or consultation in an outpatient location with a specialist. 
 
 You have been asked to pay a total of $225 ($25 copayment x 9 visits= $225) for the specialist visits. Specialist 
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 copayment for the specialist visits provided from January 6, 2021, to 
November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays (D0220, D0230 x 5) provided on 
December 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that these extra costs were not discussed with you. 
You say that you would like the office to write off these charges. You also say that this practice should be 
looked into as they do not call you back. The Plan denied your request. The Plan says periapical x-rays are not 
listed as covered services. The Plan also says that your plan offers a dental rider, however you were not 
enrolled in it on the date of service in this case. 
 
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 the 
periapical x-rays (D0220, D0230 x 5) provided on December 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 3, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you went for a mammogram rather 
than an ultrasound so this should be covered under your mammogram benefit. The Plan denied your request. 
The Plan says the copayment 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 $100 per 
day for Medicare-covered diagnostic radiology services.  
 
 You have only been asked to pay $93.87. Since the allowed amount was only $93.87 the Plan applied that 
amount as your copayment rather than the standard $100 copayment. 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 ultrasound provided on January 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the treatment of retinopathy provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for the treatment of retinopathy. You say that the procedure was 
not a surgery it was a laser procedure for bleeding of your eye. 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 $375 
copayment for in-network outpatient surgery at an outpatient hospital.  
 
According to Medicare, the treatment of retinopathy is considered a surgical procedure. You have been asked 
to pay a $375 copayment for the treatment of retinopathy. The treatment of retinopathy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the treatment of 
retinopathy provided on December 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on November 16, 
2021, and December 14, 2021. 
 
You asked the Plan to waive the coinsurance for injections. You say that you were distraught over the charges 
and that you have made no changes to your monthly injections. 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 20% of 
the total cost for Medicare-covered Part B prescription drugs, which includes your injections. 
 
 You have been asked to pay a total of $1,154.28 for the injections.  
 
Date of Service Allowed Amount Standard Cost Member Liability 
November 16, 2021 $2,885.70 20% $577.14 
December 14, 2021 $2,885.70 20% $577.14 
TOTAL:   $1,154.28 
 
Injections fall within the Medicare Part B prescription drugs benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for injections provided on November 16, 2021, and December 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the occupational therapy visits provided on 
September 23, 2021, September 28, 2021, October 5, 2021 and October 6, 2021. 
 
You asked the Plan to waive the copayment for occupational therapy. You say that you received a new medical 
bill, you would like it reviewed and taken care of. The Plan denied your request. The Plan says copayment 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 $40 
copayment for each Medicare-covered occupational therapy visit. You pay these amounts until you reach the 
out-of-pocket maximum.  
 You have been asked to pay a total of $135.31, which is less than the standard cost for 4 occupational therapy 
visits because you met your maximum out-of-pocket. Occupational therapy falls within the Outpatient 
Rehabilitation 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 the 
occupational therapy visits provided on September 23, 2021, September 28, 2021, October 5, 2021 and October 
6, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the bone replacement graft for ridge preservation (D7953) provided on 
January 4, 2022. 
 
You asked the Plan to pay for the bone replacement graft. You say that this service is clearly shown as a 
covered dental service in the optional enhanced dental plan, and is payable at 50% of the approved fee. The 
Plan denied your request. The Plan says that this oral surgical procedure is regarded as a medical benefit. 
 
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. The Plan did not provide evidence that you were not enrolled in the Plan's 
Optional Enhanced Dental Benefits on January 4, 2022. The documentation provided shows a bill you received 
for the Enhanced Dental Benefits, which you state you paid for online on December 22, 2021, and also enrolled 
in autopay for all future premiums. The documentation does not support that you had a lapse in coverage. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the bone replacement graft for ridge preservation (D7953) provided on January 4, 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.