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

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on April 
12, 2022, to April 13, 2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you should not have to pay 
for the visit, you were kept overnight for observation. 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 $100 
copayment for emergency care. 
 
You have been asked to pay a $100 copayment for emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan.  Therefore, we decided that the Plan does not have to waive the copayment for emergency room visit 
provided on April 12, 2022, to April 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van transportation provided on February 19, 
2022. 
 
You asked the Plan to pay for wheelchair van transport. You say that the hospital arranged for someone to take 
you home and told you that you had to pay for it. The Plan denied your request. The Plan says this trip was not 
arranged through the Plan's routine transportation services and prior authorization was not obtained. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when scheduled through the Plans routine transportation services and to a Plan-approved location.  
 
We looked at your request, the records in the case file, and the rules. This trip was not arranged through the 
Plans routine transportation services and was not approved by the Plan. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pay for wheelchair van transportation provided on February 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7210) and the placement of intra-
socket biological dressing to aid in hemostasis or clot stabilization (D7922) provided by an out-of-network 
provider on July 6, 2022. 
 
You asked the Plan to pay for a surgical extraction and the placement of intra-socket biological dressing to aid 
in hemostasis or clot stabilization. You say that you thought that this would be covered. The Plan denied your 
request. The Plan says the rendered dental services 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 a surgical extraction (D7210) and the placement of intra-socket biological dressing to aid in hemostasis or clot 
stabilization (D7922) provided by an out-of-network provider on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0366) provided by an out-of-
network provider on June 16, 2022. 
 
You asked the Plan to pay for a cone beam CT capture. You say that this should be covered because it was 
medically necessary. The Plan denied your request. The Plan says the rendered dental work 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 a cone 
beam CT capture (D0366) provided by an out-of-network provider on June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on May 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were not aware that a referral was needed. The 
Plan denied your request. The Plan says a referral/authorization was not obtained prior to services being 
rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a specialist office visit provided on May 25, 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 a domiciliary or rest home visit provided on June 13, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
the member's Plan excludes coverage for this out-of-network service. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam (92002) provided on May 9, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the eye exam. 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 eye exam (92002) provided on May 9, 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 nerve test (D0460) and the computed tomography (CT) 
scan provided on July 27, 2022. 
 
You asked the Plan to pay for the nerve test (D0460) and the CT scan (D0364). You say that you were told the 
provider was in-network and the services should be covered. The Plan denied your request. The Plan says the 
services 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 the nerve 
test (D0460) and the computed tomography (CT) scan provided on July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 8, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the claim to be processed 
for payment. The Plan denied your request. The Plan says the rendering and referring providers are both OON 
providers and there was no approved authorization. Also, the service rendered was not urgent or emergent. 
  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 the laboratory services provided on December 8, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for each additional intraoral-periapical x-rays (D0230 x4) 
provided on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were assured the x-rays were 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 August 8, 2022. 
Therefore, we decided that the Plan does not have to pay for each additional intraoral-periapical x-rays (D0230 
x4) provided on August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on June 
13, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the labs were for yoiur 
annual physical. 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 $6.56 
copayment for laboratory tests that are not FIT tests. 
 
You have been asked to pay a $6.56 copayment for the laboratory services. This item/service falls within the 
laboratory tests that are not FIT 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. The allowed amount for the laboratory test is $6.56. Since this is less than the 
$10 copayment per the EOC, you are only responsible for the lesser amount. Therefore, we decided that the 
Plan does not have to waive the copayment for the laboratory services provided on June 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies provided on June 16, 2022. 
 
You asked the Plan to pay for incontinence supplies. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided on 
June 16, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 diagnostic services. 
 
You asked the Plan to pay for the Guardant360. You say that this was medically necessary for the enrollee. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 diagnostic services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from April 14, 2021, 
to May 7, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the initial Request for Anticipated 
Payments (RAP) claim was not received within 5 calendar days from the start of care. The Plan also says that 
the non-contracted provider submitted the full claim on May 20, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit a RAP within 5 calendar 
days after the start of care date for initial 30-day periods and within 5 calendar days after the from date for 
each subsequent 30-day period of care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home health care services provided from April 14, 2021, to May 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI provided on May 17, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you disagree with the copay and would 
like the plan to reconsider payment. 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 for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $200 copayment for the MRI. 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 the MRI provided on May 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for endoscopy, laboratory 
services and injections provided on May 3, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for endoscopy, laboratory services and injections. 
You say that the services should be covered as preventative screening. 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, a $2 copayment for laboratory services, and a 20% coinsurance for and 
Medicare Part B prescription drugs.  
 
 
You have been asked to pay a $325 copayment for an endoscopy, a $2 copayment for laboratory services and a 
20% coinsurance for and injections.  
 
 
CPT Code Allowed Amount Coinsurance Copayment Amount Being Asked to Pay 
43239 --- --- $325 $323 
J2250 $2.26 20% --- $0.45 
J3010 $3.95 20% --- $0.79 
88305 --- --- $2 $2 
 
                     Total Amount Being Asked to Pay: $323 + $0.45 + $0.79 + $2 = $326.24 
 
An endoscopy falls within the Outpatient surgery benefit category and injection fall under 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 copayment and coinsurance for 
endoscopy, laboratory services and injections provided on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for crowns (D2740) provided by a 
participating provider on February 20, 2021. 
 
You asked the Plan to waive the coinsurance for a crown. You say that the crowns fell out because the provider 
did a poor job. You say that you should not 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 20% 
coinsurance for dental services/comprehensive dental services.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for two crowns. The total allowed 
amount is $1,258.18. The total amount you are being asked to pay is $251.62 ($1,258.18 x 20% = $251.62). 
This item/service falls within the dental services/comprehensive 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 crowns (D2740) provided by a participating provider on February 
20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on 
February 08, 2022, to February 15, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. 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 $25 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $25 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. You have been asked to pay a total of $50 ($25 x 2 visits) copayment for the 
physical therapy visits. Therefore, we decided that the Plan does not have to waive the copayment for physical 
therapy visits provided on February 08, 2022, to February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) provided on June 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received the dental services from a new 
provider, and you would like the Plan to cover the dental service. 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 the date of service of June 8, 2021. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0150) provided on June 21, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the prophylaxis (D1110) provided on April 26, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the prophylaxis. You say that you have preventive dental cleaning under 
your plan, and expected this service to be covered in full. You also say you were not advised that the treating 
provider was OON. 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 OON 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 OON 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 prophylaxis (D1110) provided on April 26, 2022, by an out-of-
network (OON) provider.