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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (code D0150) and does 
not have to waive the cost share for limited oral evaluation  problem focused (code D0140), A complete 
series-intraoral radiographic images (D0210) and alveoloplasty in conjunction with extractions (code D7311) 
provided on May 5, 2022 and May 12, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the comprehensive oral evaluation (code D0150) has already been exhausted. The Plan has applied the correct 
cost share for the limited oral evaluation  problem focused (code D0140), A complete series-intraoral 
radiographic images (D0210) and alveoloplasty in conjunction with extractions (code D7311). 
 
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 comprehensive oral evaluation (code D0150) was exhausted on date of service 
December 21, 2021. Therefore, we decided that the Plan does not have to pay for comprehensive oral 
evaluation (code D0150). The records shows that the Plan applied the correct cost share to the limited oral 
evaluation  problem focused (code D0140), A complete series-intraoral radiographic images (D0210) and 
alveoloplasty in conjunction with extractions (code D7311). Therefore, we decided that the Plan does not have 
to pay an additional amount for the limited oral evaluation  problem focused (code D0140), A complete 
series-intraoral radiographic images (D0210) and alveoloplasty in conjunction with extractions (code D7311) 
provided on May 5, 2022 and May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 15, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you called the Plan in early May to update the 
primary care provider to the rendering provider but they did not complete the update. The Plan denied your 
request. The Plan says the call logs were checked and did not see where you called in May to update your 
primary care physician. 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 an office visit provided on June 15, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning (99497) provided on January 21, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the advance care planning. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 advance care planning (99497) provided on 
January 21, 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 May 27, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are providing medical records to prove the 
medical necessity. 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 an office visit provided on May 27, 2022, by OON 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 
2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the service would 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. 
 
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 18, 2018. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a limited oral evaluation (D0140) and an 
extraction (D7140) provided on April 8, 2022. 
 
You asked the Plan to waive the coinsurance for an evaluation and extraction. You say that you were told you 
would be reimbursed 100%. 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 50% 
coinsurance for out-of-network preventive and comprehensive dental services.  
 
You have been asked to pay $87.50, which is 50% coinsurance of the allowed amount for an evaluation ($175 
allowed amount x 50% coinsurance = $87.50). You have also been asked to pay $120, which is 50% 
coinsurance of the allowed amount for an extraction ($240 allowed amount x 50% coinsurance = $120). You 
have been asked to pay a total of $208.50. These items/services fall within the dental 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 coinsurance for a limited oral evaluation (D0140) and an extraction 
(D7140) provided on April 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns (D6740 x3), and pontic (D6245 x2) provided 
on May 23, 2022. 
 
You asked the Plan to pay for retainer crowns and pontic. You say that the services should be covered, and you 
want the Plan to reimburse you. The Plan denied your request. The Plan says the services at issue are not 
covered 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 retainer 
crowns (D6740 x3), and pontic (D6245 x2) provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis, adult 
(D1110) provided December 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told a third cleaning would be covered 
in 2021. 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 7, 2021, and 
August 11, 2021. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120) and prophylaxis, adult (D1110) provided December 27, 2021.  
 Your complaint about potentially receiving inconsistent or incorrect information about benefits is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 08, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you want to appeal the amount being charged. The Plan 
denied your request. The Plan says As a member of our plan, the enrollee must use network providers. If the 
enrollee receives unauthorized care from an out-of-network provider, we may deny coverage and the enrollee 
will be responsible for the entire cost. 
 
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 office visit provided on April 08, 2022, by an out-
of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound (76830) provided on January 25, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the ultrasound. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not 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 an ultrasound (76830) provided on January 25, 
2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for nuclear stress test and Part B drugs on 
May 09, 2022. 
 
You asked the Plan to waive the cost sharing for nuclear stress test and Part B drugs. You say that you want to 
appeal the amount being charged. 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 $75 
copayment for Medicare-covered Nuclear Medicine at a freestanding provider at an outpatient hospital setting. 
You must pay a 20% coinsurance for Part B medications and contrast agents injected during the service or Part 
B medications topically applied during the service. Covered services include but are not limited to other 
outpatient diagnostic tests. The provider billed in the amount of $320 and the allowed amount of $246. $246 x 
20% = $49.20. $49.20 + $75 = $124.20. Therefore, reuslts in the total cost sharing amount of $124.20. 
 
You have been asked to pay a $75 copayment for nuclear stress test and 20% coinsurance for Part B drugs. 
This item/service 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 cost sharing for nuclear stress test and Part B drugs on May 
09, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for closure of the lacrimal punctum, by plug, each (68761) and 
permanent, long term, non-dissolvable lacrimal duct implant, each (A4263) provided January 26, 2022. 
 
You asked the Plan to pay for the outpatient visit. You say that CPT code 68761 should not have been denied 
included in allowance with another service/procedure that was performed. The diagnosis code for this claim 
has been updated to M35.01, which is not the same diagnosis code as the procedure performed December 16, 
2021. The Plan denied your request. The Plan says unbundled service. Service included in Global package. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that procedure code A4263 has a status indicator of 'B' and is always bundled 
into payment for other services not specified and no separate payment is made per Medicare. You can find this 
rule in the Medicare National Physician Fee Schedule Relative Value File. For procedure codes 68761-E2 and 
68761-E4, the records show this provider rendered procedure code 66984, extracapsular cataract removal with 
insertion of lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration 
or phacoemulsification); without endoscopic cyclophotocoagulation, on date of service December 16, 2021. 
Surgery procedure 66984 has a global value of 090 on the CMS National Physician Fee Schedule (NPFS) 
Relative Value (RVU) file. This is a minor procedure that has a global surgery period of 90 days. Procedure 
codes 68761-E2 and 68761 E4 billed on date of service January 26, 2022 and rendered by the same provider 
are within the global surgery package of procedure 66984 billed on date of service December 16, 2021. Based 
on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does 
not have to pay for closure of the lacrimal punctum, by plug, each (68761) and permanent, long term, non-
dissolvable lacrimal duct implant, each (A4263) provided January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 16, 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 May 16, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomographic angiography 
(CTA) of the neck provided to the enrollee on August 23, 2021. 
 
You asked the Plan to waive the copayment for the CTA of the neck. You say that the scan was done for a 
lifesaving surgery and the copayment should be waived. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $200 copayment for advanced imaging services (CT scan).  
 
The enrollee has been asked to pay a $200 copayment for the CTA of the neck. This item/service falls within 
the advanced imaging services (CT scan) benefit category. This means that the enrollee has been asked to pay 
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomographic angiography (CTA) of the neck provided to the enrollee on August 23, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental extraction (CPT code D7210) to be provided 
by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that you need this tooth extracted and want to 
have it done before it becomes painful. The Plan denied your request. The Plan says dental services performed 
by an oral surgeon 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, the requested items or services are not among those covered 
under this benefit. Your 2022 EOC states services must be performed by a participating general dentist. Dental 
services performed by an oral surgeon are not covered. Therefore, we decided that the Plan does not have to 
pre-approve the dental extraction (CPT code D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010), bone graft (D6104), guided 
tissue regeneration (D4266), deep sedation (D9222, D9223), extractions (D7210), a panoramic x-ray (D0330), 
therapeutic parenteral drugs (D9610), and an unspecified preventive procedure (D1999) provided on May 11, 
2021. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered under your 
medical coverage. The Plan denied your request. The Plan says the requested items and services are not 
covered. 
 
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 an endosteal implant (D6010), 
bone graft (D6104), guided tissue regeneration (D4266), deep sedation (D9222, D9223), extractions (D7210), a panoramic x-ray (D0330), therapeutic parenteral drugs (D9610), and an unspecified preventive procedure 
(D1999) provided on May 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy injections provided on 
April 21, 2022, to May 12, 2022. 
 
You asked the Plan to waive the coinsurance for the chemotherapy injections. You say that you cannot afford 
the coinsurance for the services. 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. 
 
You have been asked to pay 20% coinsurance for the chemotherapy 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 the chemotherapy injections provided on April 21, 2022, to May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve an SCS to be provided by an out-of-network provider. You say that you 
disagree with the denial of a spinal cord stimulator being provided by an out-of-network provider. The Plan 
denied your request. The Plan says the SCS can be provided by an in-network 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a spinal cord stimulator (SCS) to be provided by an out-of-network (OON) provider.