Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for observation services provided on July 19, 
2022, to July 20, 2022. 
 
You asked the Plan to waive the copayment for observation services. You say that you shouldnt have to pay 
for this. 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 $340 
copayment for Outpatient hospital observation. 
 
You have been asked to pay a $340 copayment for observation services. This item/service falls within the 
Outpatient hospital observation benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
observation services provided on July 19, 2022, to July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) and core buildup 
including any pins, when required (D2950) provided on July 12, 2022, and July 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you broke a tooth and needed to find a dentist 
that takes your insurance, so you should not have to pay this bill. 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. This benefit includes the 
requested item or service but is limited to an annual maximum of $1,000. The requested core buildup including 
any pins, when required (D2950) is not covered under this benefit. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan paid 
$93 for services on July 12, 2022, and $907 for services on July 29, 2022, which is the annual maximum of 
$1,000. The record shows your benefit for the requested item or service was exhausted on date of service July 
29, 2022. Therefore, no additional payment will be made for crown - porcelain/ceramic (D2740). The requested 
core buildup including any pins, when required (D2950) is not covered under the Plans dental benefits. 
Therefore, we decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) and core 
buildup including any pins, when required (D2950) provided on July 12, 2022, and July 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 06, 
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 $225 
copayment for Outpatient surgery in an ambulatory surgical center. 
 
You have been asked to pay a $225 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in an ambulatory surgical center 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 outpatient surgery provided on August 06, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on June 20, 
2022, to June 27, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you shouldnt have to pay for 
this. 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 $325 
copayment for Outpatient surgery in an ambulatory surgical center. 
 
You have been asked to pay a $325 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in an ambulatory surgical center 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 a $325 copayment per surgery ($325 
x 2 visits) for a total of a $650 copayment. Therefore, we decided that the Plan does not have to waive the 
copayment for outpatient surgery provided on June 20, 2022, to June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that your old dentist went out-of-network and you 
were forced to find a new dentist. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 7, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit and Part B drugs provided on 
October 5, 2021. 
 
You asked the Plan to waive the cost share for an office visit and Part B drugs. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $30 copayment for each specialist visit. 
 
You have been asked to pay 20% coinsurance for Part B drugs. This item/service falls within the Medicare Part 
B prescription drugs benefit category. You have also been asked to pay a $30 copayment for the specialist 
office visit. This falls within the Physician/Practitioner services, including doctors 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 cost share for an office visit and Part B drugs provided on 
October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames, vision services purchases (V2020) provided on 
August 17, 2022. 
 
You asked the Plan to pay for frames, vision services purchases (V2020). You say that you want to appeal the 
reimbursement denial for the purchase of eyeglasses. The Plan denied your request. The Plan says this was not 
referred by a primary care provider, nor was this service authorized.  
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 authorization is obtained for out-of-network covered services. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a point of service option for out-of-
network services. However, there is no out-of-network coverage without authorization. The record shows no 
authorization was obtained prior to this service. Based on this information, we decided that the Plan's rules for 
coverage of frames, vision services purchases (V2020) have not been met. Therefore, we decided that the Plan 
does not have to pay for frames, vision services purchases (V2020) provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a removal of benign odontogenic cyst or tumor (D7450) 
provided on June 27, 2022. 
 
You asked the Plan to pay for a removal of benign odontogenic cyst or tumor - (D7450). You say that this was 
a surgery and should have been billed to your medical insurance. You also say that when you brought this to 
the provider's attention, they said they do not bill to medical. The Plan denied your request. The Plan says there 
is no coverage for the removal of benign odontogenic cyst/tumor lesion (D7450). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a removal 
of benign odontogenic cyst or tumor (D7450) provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0150), x-rays (D0210), and a filling 
(D2393) for tooth #9 provided on June 28, 2022, and July 12, 202. 
 
You asked the Plan to pay for the dental services. You say that you were told the dentist was an in-network 
provider and you would like the dental services paid. 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. 
The Plan also says that a list of in-network providers was given to the enrollee on April 7, 2022. 
 
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 oral evaluation (D0150), x-rays (D0210), and a filling (D2393) for tooth #9 provided on June 28, 
2022, and July 12, 202.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on August 
05, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you cannot afford this 
charge. 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 $20 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for physical therapy visits. This item/service 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 
physical therapy visits provided on August 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy on tooth #16 (D3330) provided on 
August 2, 2022. 
 
You asked the Plan to pay for endodontic therapy. You say that the root canal was medically necessary. The 
Plan denied your request. The Plan says your annual dental benefit has been exhausted. 
 
 
 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 this benefit includes 
coverage up to $1,000 for preventive and comprehensive dental services. You are responsible for any amount 
above the benefit limit.   
 
The record shows your annual dental benefit has already been exhausted. You have been asked to pay $1,375 
for endodontic therapy on tooth #16. This item/service falls 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 pay for endodontic therapy on tooth #16 (D3330) provided on August 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) provided on August 16, 2022. 
 
You asked the Plan to pay for core buildup (D2950). You say that the only reason you had this done was 
because the tooth was fractured and had decay. You also say you thought that with decay, the procedure would 
be partially covered. The Plan denied your request. The Plan says there is no coverage for core buildup. 
 
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 core 
buildup (D2950) provided on August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital, binaural hearing aid (V5261) provided on August 
11, 2022. 
 
You asked the Plan to pay for a digital, binaural hearing aid (V5261). You say that on the annual notice of 
changes for 2022, it clearly states that hearing aids are covered. You also say that you were told by the Plan's 
customer care representatives that the hearing aids would be covered as out-of-network care. The Plan denied 
your request. The Plan says a specific Plan provider must be used for in- and out-of-network hearing aid 
benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only they are provided by a Plan hearing provider.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a digital, binaural hearing aid (V5261). Our 
reviewer says that  Our physician reviewer found  
 
 
  We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of a digital, binaural hearing aid (V5261) have not been met. Therefore, we 
decided that the Plan does not have to pay for a digital, binaural hearing aid (V5261) provided on August 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the laboratory services were medically 
necessary. The Plan denied your request. The Plan says there was no prior authorization on file. 
 
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 laboratory services provided on July 20, 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 sinus augmentation (D7952) provided by a participating 
provider on July 25, 2022. 
 
You asked the Plan to pay for sinus augmentation. You say that you needed these services. 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 sinus 
augmentation (D7952) provided by a participating provider on July 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair with multiple 
power options (K0841) and related accessories and features. 
 
You asked the Plan to pre-approve a Group 2 standard power wheelchair and related accessories. You say that 
the requested items are a medical necessity for you. The Plan denied your request. The Plan says the request 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 asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 2 standard power wheelchair 
and related accessories. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the criteria for the tilt and recline power seating 
system are not met. You do not have high risk for skin breakdown and do not have spasm or intermittent 
catheterization. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 2 standard power wheelchair and related accessories have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair 
with multiple power options (K0841) and related accessories and features.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on August 
5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not want the Plan to deny your dentist 
for fixing  your tooth. You also say it is a 20 year old crown, with a cavity under it. 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 January 7, 2021. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided 
on August 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Varithena. 
 
You asked the Plan to pre-approve Varithena. You say that the requested Varithena is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for Varithena. 
 The Plan must follow Medicare rules. Medicare rules say that vascular interventions may be covered when there 
are documented CEAP and VCSS scores and clear documentation of interference with daily living or quality of life. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Varithena. Our reviewer says that the 
enrollee does not meet criteria for Varithena. Our physician reviewer found coverage criteria requires 
documentation of CEAP and VCSS in the medical record, these are not provided.  Additionally, there are 
conflicting elements in the assessment and venous duplex creating a lack of clarity with respect to the 
documentation of the enrollees symptoms.  There are elements in the progress notes suggesting that there is 
significant reflux associated with the enrollees symptoms and no mention in the narrative about prior great 
saphenous vein (GSV) ablation.  There are other portions that state the enrollee has had the great saphenous 
veins ablated.  There is similar lack of clarity within the venous duplex where there was an assessment of 
ablated great saphenous vein despite documentation of normal flows in the great saphenous vein.  There does 
not appear to be any discussion in the progress note about what benefit, if any, the enrollee experienced from 
great saphenous vein ablation.  Lastly, it is not documented what veins are intended to be treated or why 
multiple sessions of both treatment of one vein or treatment of multiple veins are needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Varithena have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Varithena.