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

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on September 20, 2022. 
 
You asked the Plan to pay for the prophylaxis. You say that you were not advised what services you were 
receiving, and thought you were only getting a cleaning. You also say that you were told your insurance would 
pay 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 benefit for the requested item or service was exhausted on date of service February 7, 2022, and 
March 15, 2022. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) 
provided on September 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT scan) provided 
on August 11, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT scan). 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 $275 
copayment for Advanced imaging services in an outpatient hospital. 
 
You have been asked to pay a $275 copayment for computed tomography (CT scan). 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. Therefore, we decided that the Plan does not have 
to waive the copayment for computed tomography (CT scan) provided on August 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the claim was denied in error. The Plan denied your 
request. The Plan says the services were provided by an out of network provider. There was no prior 
authorization on file for the services provided. 
 
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 23, 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 the dental services on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 on August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on June 02, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you were told they never 
charge for blood work. 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 $10 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for laboratory services. 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 copayment for laboratory services provided on June 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist visit provided on June 07, 2022. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you were told they never charge 
for blood work. 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 $40 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for specialist visit. This item/service 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 copayment for specialist visit provided on June 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on April 20, 
2022, to July 20, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you disagree with the 
copayments. 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 per visit for outpatient surgery.  
 
You have been asked to pay a $225 copayment per visit for outpatient surgery. The total amount you are being 
asked to pay is $675 ($225 x 3 visits = $675). 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 April 20, 2022, to July 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided on August 10, 
2022. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that you would like to know why the 
Plan did not pay anything towards the services rendered. 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 $165 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or a free-standing facility.  
 
 
  You have been asked to pay $152.11, which is less than the standard $165 copayment for a duplex scan. This 
item/service falls within the Outpatient Diagnostic Tests 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 a duplex scan provided on August 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on April 29, 
2022, to April 30, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copayment. 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 $200 
copayment per one-way trip for ambulance services. 
 
You have been asked to pay a $200 copayment per one-way trip for ambulance services. The total amount you 
are being asked to pay is $400 ($200 x 2 =$400). 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 services provided on April 29, 
2022, to April 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable medical equipment provided on 
March 21, 2022, to October 10, 2022. 
 
You asked the Plan to waive the coinsurance for Durable medical equipment. You say that you thought this 
would be covered in full. 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 Durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for Durable medical equipment. This item/service falls within 
the Durable medical equipment (DME) 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 Durable medical equipment provided on March 21, 2022, to October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150), intraoral radiographic images 
(D0210), panoramic radiographic images (D0330) and 2D facial images (D0350) provided on August 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not told there were limitations on the 
x-rays and evaluation. The Plan denied your request. The Plan says your benefit for the oral evaluation, 
intraoral radiographic images, and the panoramic radiographic images has already been exhausted. Also, the 
denial of payment for the 2D facial images is correct, because it is 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, certain limitations apply. The record 
shows your benefit for the oral evaluation, intraoral radiographic images, and the panoramic radiographic 
images was exhausted on the date of service of May 20, 2022. Also, the 2D facial images is not covered under 
the Plans dental benefit. Therefore, we decided that the Plan does not have to pay for an oral evaluation 
(D0150), intraoral radiographic images (D0210), panoramic radiographic images (D0330) and 2D facial 
images (D0350) provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an extraction of an 
erupted or exposed root (D7140) for teeth numbers 3, and 5 provided on May 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you could not reach the in-network provider, so 
you went out to find someone. You also say you called the in-network provider, and they did not do the 
extractions of the roots, so you called around. 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 a comprehensive oral evaluation (D0150), an extraction of an erupted or exposed root (D7140) for 
teeth numbers 3, and 5 provided on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused tooth #'s 01 and 
32 (D0140), and panoramic radiographic image tooth #31 (D0330) provided on August 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were in pain and needed the root canal. The 
Plan denied your request. The Plan says your benefit for the limited oral evaluation - problem focused (D0140) 
service has already been exhausted. 
 
The Plan also says the panoramic radiographic image (D0330) out-of-network liability was applied correctly 
per the Plan 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, certain limitations apply. The record 
shows your benefit for the limited oral evaluation - problem focused (D0140) was exhausted on date of service 
August 10, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - 
problem focused tooth #'s 01 and 32 (D0140), and panoramic radiographic image tooth #31 (D0330) provided 
on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740), and to pay for the core buildup 
(D2950) and the pulp cap (D3120) for tooth #31 provided on August 8, 2022. 
 
You asked the Plan to pay more for the crown and pay for the core buildup and pulp cap. You say that this is 
the first time you used your dental benefits, and you would like the Plan to cover up to the maximum allowed 
amount. 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. Also, the denial 
of payment for the core buildup and pulp cap is correct, because they 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. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the crown. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan.  Also, the core buildup and pulp cap are not covered under the Plans dental benefit. Therefore, we 
decided that the Plan does not have to pay more for a crown (D2740), and to pay for the core buildup (D2950) 
and the pulp cap (D3120) for tooth #31 provided on August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on 
September 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have not exceeded any limits. 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 29, 2021. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on 
September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services were rendered in good faith and were 
medically necessary. The Plan denied your request. The Plan says services from a non-participating provider 
are not covered unless there is an 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 an office visit provided on March 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy services provided from 
April 26, 2022, to May 16, 2022. 
 
You asked the Plan to waive the copayments for physical therapy services. You say that you were told by the 
provider that you did not owe anything and then you received a bill. You say you spoke with the Plan after 
receiving the bills and they informed you of the $20 copayment for physical therapy visits. 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 each Medicare-covered outpatient rehabilitation service, treatment or evaluation.  
 
 
  You have been asked to pay a total copayment of $140 for physical therapy services ($20 per visit x 7 visits = 
$140). 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 copayments for physical therapy services provided from April 26, 2022, to May 16, 
2022.  
 
Your complaint about the provider not informing you of the copayment 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 waive the copayment for wound care services provided from June 7, 
2022, to June 30, 2022. 
 
You asked the Plan to waive the copayment for the wound care services. You say that you were unaware of the 
cost of 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 a $250 
copayment for surgery or other services at an outpatient hospital or ambulatory surgical center.  
 
 
  You have been asked to pay a $250 copayment for each of the 2  wound care services. You have also been 
asked to pay $128 for the compression bandage application, which is less than the $250 copayment per the 
EOC. The total for all services is $628. This item/service falls within the surgery or other services at an 
outpatient hospital or 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 wound care services provided from June 7, 2022, to June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a gym membership provided from January 1, 2022, to 
July 1, 2022. 
 
You asked the Plan to reimburse for a gym membership. You say that you called in to the plan and were 
informed that you would be able to get reimbursed from January 2022 to July 2022. The Plan denied your 
request. The Plan says the calls you made to customer service were made after the dates of service, and not 
prior to them. The Plan also says that the fitness enrollment and the activation code were not obtained prior to 
services rendered. 
 
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 when the member gets the confirmation code before the starting the program/club. 
 
 
  The Plans rules for coverage of gym benefits have not been met because The Plan rules say that you need a 
confirmation code to get started. Therefore, we decided that the Plan does not have to reimburse for a gym 
membership provided from January 1, 2022, to July 1, 2022.