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

 
We decided that the Plan does not have to pay for the laboratory services provided on June 27, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you feel the claim should be covered as 
you have insurance coverage. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 4, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on June 13, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered. 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 $300 
copayment for Ambulance services. 
 
You have been asked to pay a $300 copayment for ambulance transport. This item/service falls within the 
Ambulance 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 ambulance transport 
provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral examination (D0150) and the 
intraoral x-rays (D0210) provided on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had an infection in your teeth. You say you 
went to another dentist because you were worried about the appointment on March 10. The Plan denied your 
request. The Plan says your benefit for the dental 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 item or service was exhausted on date of service March 29, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral examination (D0150) and 
the intraoral x-rays (D0210) provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 23, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on September 21, 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 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 9/21/22. Therefore, we 
decided that the Plan does not have to pay for dental services provided on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 3, 
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 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 08/23/2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 3, 
2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D2391, D5214, D9310, D2750) provided 
on July 30, 2022 to August 30, 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 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 dental services (D2391, D5214, D9310, D2750) provided on July 30, 2022 to August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral examination (D0140) provided on September 
22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed this visit prior to your root canal. 
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 March 21, 2022, and 
September 6, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral examination 
(D0140) provided on September 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for imaging provided on September 07, 2022. 
 
You asked the Plan to waive the copayment for imaging. You say that this should be covered. 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 $225 
copayment for Advanced imaging services in an outpatient hospital. 
 
You have been asked to pay a $225 copayment for imaging. This item/service falls within the Advanced 
imaging services in an outpatient hospital 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. You have been asked to pay $99.26 which is less than the standard $225 
copayment for advanced imaging services. Therefore, we decided that the Plan does not have to waive the 
copayment for imaging provided on September 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, a COVID-19 test, and an influenza virus 
vaccination provided on September 15, 2021, to September 30, 2021. 
 
You asked the Plan to pay for an office visit, a COVID-19 test, and an influenza virus vaccination. You say that 
you were not aware that this provider was not participating with the Plan. The Plan denied your request. The 
Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit, a 
COVID-19 test, and an influenza virus vaccination provided on September 15, 2021, to September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on August 3, 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 services denied correctly as they do not fall 
within 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 an 
intraoral x-ray (D0210) provided on August 3, 2022
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood draw (36415), basic metabolic panel (80048), and 
travel allowance for collection of medically necessary laboratory services (P9603) provided on August 26, 
2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was not enrolled in hospice on 
this date. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 4, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the blood draw 
(36415), basic metabolic panel (80048), and travel allowance for collection of medically necessary laboratory 
services (P9603) provided on August 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 08, 
2022, to August 30, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that this should be covered. 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 $250 
copayment for Outpatient surgery. 
 
You have been asked to pay a $250 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery 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. You have been asked to pay $1,250 ($250 x 5 visits) copayment for your outpatient surgical 
procedures. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery 
provided on March 08, 2022, to August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided 
on December 15, 2021 to June 22, 2022 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis 
provided on December 15, 2021 to June 22, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoride and periodontal maintenance services (D4910, 
D1206) provided on June 15, 2022 to September 26, 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 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 June 15, 2022. Therefore, 
we decided that the Plan does not have to pay for fluoride and periodontal maintenance services (D4910, 
D1206) provided on June 15, 2022 to September 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says SNF care beyond 100 days per benefit period is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 The file shows that you received 100 days of SNF care during the benefit period from March 9, 2022, through 
November 5, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cold temperature ablation (64999). 
 
You asked the Plan to pre-approve a cold temperature ablation. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a cold temperature ablation have not been met. Specifically, Non-thermal modalities for facet joint 
denervation including chemical, low-grade thermal energy (less than 80 degrees Celsius), laser neurolysis, and 
cryoablation are considered not medically necessary or reasonable. Therefore, we decided that the Plan does 
not have to pre-approve a cold temperature ablation (64999).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for diagnostic radiology service and Medicare 
Part B prescription drugs provided on August 24, 2022. 
 
You asked the Plan to waive the cost share for diagnostic radiology service and Medicare Part B prescription 
drugs. 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 $95 
copayment for outpatient diagnostic tests and therapeutic services and supplies and 20% coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay $95 copayment for diagnostic radiology service and 20% coinsurance Medicare 
Part B prescription 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 share for diagnostic radiology service 
and Medicare Part B prescription drugs provided on August 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 30, 2022. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home health services 
provided on September 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 19, 2022. 
 
You asked the Plan to pay for home health services. You say that it was medically necessary for this patient to 
be seen to adequately develop an effective treatment plan. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home health services 
provided on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0274, D1110, D9910, D0120) provided 
on August 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your benefit maximum allowance 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 February 1, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services (D0274, D1110, D9910, 
D0120) provided on August 2, 2022.