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

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on June 14, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility services. You say that the records attached support the 
services rendered. The Plan denied your request. The Plan says there is no prior authorization on file for the 
services 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 skilled nursing facility services provided on June 
14, 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 an extraction (D7140) provided by an out-of-network 
provider on August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should not owe anything for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual maximum dental allowance was exhausted on date of service July 27, 2022. Therefore, we 
decided that the Plan does not have to pay for an extraction (D7140) provided by an out-of-network provider 
on August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusion analysis (D9950) provided by a participating 
provider on July 28, 2022. 
 
You asked the Plan to pay for an occlusion analysis. You say that these services were not provided for cosmetic 
reasons. The Plan denied your request. The Plan says the rendered dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
occlusion analysis (D9950) provided by a participating provider on July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit, xray, and MRI provided on 
May 20, 2022, to May 27, 2022. 
 
You asked the Plan to waive the copayment for specialist visit, xray, and MRI. You say that you are disputing 
the share cost. 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 $45 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $45 copayment for each specialist visit and $40.44, which is less than the $60 
copayment for xray, and $150 copayment for MRI. These items/services fall within the physician/practitioner 
services, including doctor's office visits and outpatient diagnostic tests and therapeutic services benefit categories. 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 specialist visit, xray, and MRI provided on 
May 20, 2022, to May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alveoloplasty in conjunction with extractions - four or more 
teeth or tooth spaces, per quadrant (D7310) and removal of torus mandibularis (D7473) provided on July 12, 
2022. 
 
You asked the Plan to pay for dental services. You say that the services should be covered, and you should not 
have to pay. 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. Alveoloplasty in conjunction 
with extractions - four or more teeth or tooth spaces, per quadrant (D7310) and removal of torus mandibularis 
(D7473) are not covered under the Plans dental benefits. 
 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 
alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310) and 
removal of torus mandibularis (D7473) provided on July 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on May 30, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service provided to the enrollee was 
out of medical necessity. The Plan denied your request. The Plan says the enrollee was in hospice during the 
date of service; therefore, payment for the service was denied. 
 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 the nursing facility care provided on May 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on April 29, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you are disputing the share cost. 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 Medicare Part B prescription drugs. The allowed amount of these injections total $1,836.26, 
resulting in a coinsurance amount of $367.25. 
 
You have been asked to pay 20% coinsurance for injections. This item/service 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 injections provided 
on April 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transportation - wheelchair van provided 
on July 8, 2022. 
 
You asked the Plan to pay for the non-emergency transportation - wheelchair van. You say that you were not 
aware that wheelchair transport is not covered under your plan.  The Plan denied your request. The Plan says 
transports by wheelchair van or ambulette and trips to or from a physician's office are not covered under any 
condition by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the non-emergency transportation - wheelchair van provided on July 8, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on August 31, 
2022, by OON provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
the out-of-network services were not authorized. 
 
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 
August 31, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral photographic images (D0350) and the oral hygiene 
instructions (D1330) provided on August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the images were needed, and you were never 
told the procedures were not covered. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the oral photographic images and the oral hygiene instructions 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 the oral 
photographic images (D0350) and the oral hygiene instructions (D1330) provided on August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network office visit provided on 
June 22, 2022. 
 
You asked the Plan to waive the coinsurance for out-of-network office visit. You say that you are disputing the 
share cost. 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 40% 
coinsurance for physician/practitioner services, including doctor's office visits. The allowed amount of this 
office visit total $178.93, resulting in a copayment amount of $71.57. 
 
You have been asked to pay 40% coinsurance for out-of-network office visit. This item/service falls 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 coinsurance for out-of-network office visit provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a tennis club provided on January 1, 2022. 
 
You asked the Plan to reimburse for a tennis club. You say that you go to this club because it keeps you active, 
in motion, and in shape. The Plan denied your request. The Plan says per the EOC, this benefit does not cover 
membership fees you pay to non-qualified health clubs or fitness facilities, including but not limited to, sports 
clubs; and for sports activities such as golf and tennis. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only the facility or club is a qualified health club or facility. 
 
 
  The Plans rules for coverage of gym benefits have not been met because The Plan rules cover membership in a 
qualified health club or fitness facility. This benefit does not cover membership fees you pay to non-qualified 
health clubs or fitness facilities, including sports clubs and social clubs; and for sports activities such as golf 
and tennis. Therefore, we decided that the Plan does not have to reimburse for a tennis club provided on 
January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341) provided on March 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel these services are medically necessary. 
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 periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided on March 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
intraoral x-ray series (D0210) provided on July 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are asking for reconsideration of the 
frequency limitation since you received no dental care during the first two years of coverage. The Plan denied 
your request. The Plan says that your benefit for the requested items or services 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 items or services was exhausted on date of service February 14, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 
complete intraoral x-ray series (D0210) provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) and a determination of 
refractive state (92015) provided on August 4, 2022.  
You asked the Plan to pay for a medical eye examination (92014) and a determination of refractive state 
(92015). You say that it is your understanding that the Plan pays for eye examinations. The Plan denied your 
request. The Plan says these services are not covered as the provider is not in the Plan optical provider network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received with an in-network optical provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that any benefits received at a non-network optical 
provider are excluded from this benefit. The record shows these services were not received in-network. Based 
on this information, we decided that the Plan's rules for coverage of a medical eye examination (92014) and a 
determination of refractive state (92015) have not been met. Therefore, we decided that the Plan does not have 
to pay for a medical eye examination (92014) and a determination of refractive state (92015) provided on 
August 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed service visit provided on 
May 2, 2022. 
 
You asked the Plan to waive the copayment for urgently needed service visit. You say that you are disputing 
the share cost. 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 $120 
copayment for urgently needed services.  
 
You have been asked to pay $120 copayment for urgently needed service visit. This item/service falls within 
the urgently needed 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 urgently 
needed service visit provided on May 2, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency services provided on July 25, 
2022, to July 26, 2022. 
 
You asked the Plan to waive the copayment for emergency services. You say that you are disputing the share 
cost. 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 $90 
copayment for outpatient hospital services.  
 
You have been asked to pay $90 copayment for emergency services. This item/service falls within the 
outpatient hospital 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 emergency 
services provided on July 25, 2022, to July 26, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayments for hospital observation care provided from June 30, 
2022, to July 1, 2022. 
 
You asked the Plan to waive the copayments for the hospital observation care. You say that you only saw the 
doctor for five minutes. The Plan denied your request. The Plan says that 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 enrollees must pay a $0 copayment for outpatient hospital observation. for 
outpatient hospital observation.  
 
The Plan says you must pay a $10 copayment for each day of hospital observation care. Based on the Plan 
contract, however, you cannot be asked to pay more than a $0 copayment for the hospital observation care. 
Therefore, we decided that the Plan has to waive the copayments for hospital observation care provided from 
June 30, 2022, to 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 22, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this should be paid for. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 22, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 6, 
2022.