Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a physical therapy visit provided on July 
22, 2022, by an out-of-network provider. 
 
You asked the Plan to waive the coinsurance for a physical therapy visit. You say that the physical therapy 
visits should have been processed as in-network and was verified prior to services being 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 40% 
coinsurance for each out-of-network Medicare-covered physical and speech therapy service.  
 
  You have been asked to pay a coinsurance of $42.41, which is 40% of the allowed amount for a physical 
therapy visit ($106.03 allowed x 40% = $42.41). 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 coinsurance for a physical therapy visit 
provided on July 22, 2022, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic test provided on 
September 26, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic test. 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 $180 
copayment for outpatient diagnostic test.  
 
You have been asked to pay a $180 copayment for outpatient diagnostic test. This item/service falls within the 
outpatient diagnostic test 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 
diagnostic test provided on September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that you are 
appealing the denial as this is a medical necessity. The Plan denied your request. The Plan says the rules for a 
therapeutic continuous glucose monitor (CGM) have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to certain brands of 
products and this plan only covers Freestyle Libre CGMs. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330) provided on July 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to a new dentist, and they needed 
these x-rays. 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 1, 2019. 
Therefore, we decided that the Plan does not have to pay for panoramic imaging (D0330) provided on July 21, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) and 
application of medicament (D9910) provided on October 3, 2022, and October 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider did not tell you that they were no 
longer in-network. The Plan denied your request. The Plan says the periodontal scaling and root planing was 
received from an out-of-network provider and is not covered by your supplemental benefits. Also, the denial of 
payment for the application of medicament 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. 
 
  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 periodontal scaling and root planing is not covered 
under this benefit when received from an out-of-network provider. The application of medicament is not 
covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal scaling and root planing (D4341) and application of medicament (D9910) provided on October 3, 
2022, and October 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on August 17, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. 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 domiciliary or rest home 
visit provided on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on April 27, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that this was medically necessary and should be 
covered. We were unaware they were out of network. 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 wound care supplies 
provided on April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on July 22, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the enrollee was in an assisted 
living facility at the time and the provider is not responsible for obtaining authorization. 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 domiciliary or rest 
home visit provided on July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric stimulation therapy (97014) provided on 
September 14, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the electric stimulation therapy (97014) provided on September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and bone 
replacement graft for ridge preservation - per site (D7953) provided on August 25, 2022. 
 
You asked the Plan to pay for dental services. You say that you do not believe the billed procedure was 
performed; therefore, you should not have to pay for the procedure. The Plan denied your request. The Plan 
says these services are not covered under your 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. Limited oral evaluation - 
problem focused (D0140) and bone replacement graft for ridge preservation - per site (D7953) are not covered 
under the Plans dental benefits.  
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 limited 
oral evaluation - problem focused (D0140) and bone replacement graft for ridge preservation - per site (D7953) 
provided on August 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on August 24, 2022. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral image (D0220), a cone beam CT capture 
(D0364), and endodontic therapy (D3320), on September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were in a lot of pain. 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 an intraoral image (D0220), a cone beam CT capture (D0364), and endodontic therapy (D3320), on 
September 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility stay provided 
from June 1, 2022, to July 1, 2022. 
 
You asked the Plan to waive the copayment for the skilled nursing facility stay. You say that you were not told 
that you would be charged. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 
copayment each day for days 120, and a $188 copayment each day for days 21100, each benefit period, for 
Medicare-covered Skilled Nursing Facility care. You can find this information on page 104 of the Plan's 2022 
Evidence of Coverage (EOC). 
 
 
 You have been asked to pay a $2068 copayment for the 31-day skilled nursing facility stay ($0 x 20 days = $0) 
($188 x 11 days = $2068). This item/service falls within the skilled nursing facility (SNF) 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 a 31-day skilled nursing facility stay provided 
from June 1, 2022, to July 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone graft for repair of peri-implant defect  does not include 
flap entry and closure (D6103) provided on January 27, 2022. 
 
You asked the Plan to pay for dental services. You say that your provider said this was a required procedure; 
therefore, you should not be responsible for payment. The Plan denied your request. The Plan says this service 
is not covered under your 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. Bone graft for repair of peri-
implant defect  does not include flap entry and closure (D6103) is not covered under the Plans dental 
benefits. 
 
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 bone graft 
for repair of peri-implant defect  does not include flap entry and closure (D6103) provided on January 27, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns (D6750), and pontics (D6240) provided on 
August 31, 2022. 
 
You asked the Plan to pay for retainer crowns and pontics. You say that this dental work was medically 
necessary. 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 retainer 
crowns (D6750), and pontics (D6240) provided on August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral 
images (D0210) provided on September 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not think about having your old x-rays 
sent to your new dentist. 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), and intraoral images (D0210) provided on September 2, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310), panoramic x-ray (D0330), 
prophylaxis (D1110), comprehensive oral evaluation (D0150), bitewing x-rays (D0274), and two simple 
extractions (D7140 x2) provided on June 21, 2022, and June 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were told by the Plan that you have dental 
coverage and could go to any dentist. 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 consultation (D9310), panoramic x-ray (D0330), prophylaxis (D1110), comprehensive oral 
evaluation (D0150), bitewing x-rays (D0274), and two simple extractions (D7140 x2) provided on June 21, 
2022, and June 27, 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 a cone beam CT capture (D0364), and the treatment of root 
canal obstruction (D3331) provided on October 3, 2022. 
 
You asked the Plan to pay for a cone beam CT capture and the treatment of root canal obstruction. You say that 
both of these services were medically necessary. The Plan denied your request. The Plan says the denied 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 cone 
beam CT capture (D0364), and the treatment of root canal obstruction (D3331) provided on October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation (D0120) to be rendered by the 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve this dental service. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says dental services received from an out-of-network 
provider 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. 
 
You are requesting a dental service from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested service is not covered under this benefit when received from an 
out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a periodic oral 
evaluation (D0120) to be rendered by the out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for physical therapy visits provided on August 
3, 2022, and August 5, 2022. 
 
You asked the Plan to waive the coinsurance for physical therapy visits. You say that the physical therapy visits 
should have been processed as in-network and was verified prior to services being 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 40% 
coinsurance for each out-of-network Medicare-covered physical and speech therapy service.  
 
 You have been asked to pay a coinsurance of $212.06, which is 40% of the allowed amount for physical 
therapy visits ($212.06 allowed x 40% = $84.82). 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 coinsurance for physical therapy visits 
provided on August 3, 2022, and August 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on June 8, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. 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 $100 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $84.83 which is less than the $100 copayment for ultrasound. 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 ultrasound provided on June 8, 2022.