Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on March 
28, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. 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 $30 
copayment for physician/practitioner services/specialist services.  
 
You have been asked to pay a $30 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on March 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayment for x-ray services and 
specialist office visit provided on May 18, 2022. 
 
You asked the Plan to waive the coinsurance and copayment for x-ray services and specialist office visit. You 
say that you disagree with the cost share. 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% 
coinsurance for outpatient diagnostic tests/ x-ray and a $30 copayment for physician/practitioner 
services/specialist.  
 
You have been asked to pay a 10% coinsurance for x-ray services and a $30 copayment for specialist office 
visit. The total allowed amount you are being asked to pay is $18.39. The amount you are being asked to pay is 
$1.84 ($18.39 x 10% = $1.84). The total amount you are being asked to pay $31.84 ($30 + $1.84 = $31.84). This item/service falls within the outpatient diagnostic tests/ x-ray and physician/practitioner services/specialist 
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 and copayment for x-ray services 
and specialist office visit provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on July 22, 
2022. 
 
You asked the Plan to pay for the full mouth debridement. You say that you have ascertained that your policy 
covers two tooth cleanings per year. You also say that you had refrained from all dental work, other than 
emergency work, due to your high risk for COVID-19, which resulted in extra buildup that was addressed by 
this tooth cleaning. The Plan denied your request. The Plan says this procedure is not a benefit under the dental 
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, 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 full 
mouth debridement (D4355) provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) of the 
lower left, lower right, upper left, and upper right quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to receive this 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 date of service October 12, 2021. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) 
of the lower left, lower right, upper left, and upper right quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for chemical cauterization of granulated tissue 
provided on August 12, 2022. 
 
You asked the Plan to reduce the copayment for the chemical cauterization of granulated tissue. You say that 
the charges are different than previous 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 $325 
copayment for surgical services at an outpatient hospital facility.  
 
You have been asked to pay $174.18, which is less than the $325 copayment for the chemical cauterization of 
granulated tissue. This item/service falls within the surgical services at an outpatient hospital facility 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 reduce the copayment for chemical cauterization of granulated tissue 
provided on August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 September 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
July 28, 2022. 
 
You asked the Plan to waive the copayment for an 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 $400 
copayment for outpatient diagnostic tests/Medicare-covered diagnostic radiology services in a provider's office.  
 
You have been asked to pay a $400 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic tests/Medicare-covered diagnostic radiology services in a provider's office 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 an outpatient diagnostic tests provided on July 
28, 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 April 14, 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 $150 
copayment for Diagnostic radiology services. 
 
You have been asked to pay a $150 copayment for computed tomography (CT scan). This item/service falls 
within the Diagnostic radiology 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 computed tomography (CT scan) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 dental 
services on July 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips. 
 
You asked the Plan to pre-approve the additional non-emergency transportation trips. You say that you are 
asking for reconsideration for the additional transportation trips. The Plan denied your request. The Plan says 
additional trips over the fifty-two (52) in only one direction are not covered by the Plan. 
 
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 a maximum of 52 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring of physiologic parameters provided on 
May 14, 2022. 
 
You asked the Plan to pay for remote monitoring of physiologic parameters. You say that the service was 
medically necessary. 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 remote monitoring of 
physiologic parameters provided on May 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation with a medicinal agent per quadrant 
(D4921 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this service is not a covered benefit under your dental 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation with a medicinal agent per quadrant (D4921 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7120) provided on August 25, 2022. 
 
You asked the Plan to pay for the extraction (D7120). You say that you and your dentist felt that it was 
medically necessary to extract the tooth because it was no longer functional and causing you pain. The Plan 
denied your request. The Plan says the 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 the 
extraction (D7120) provided on August 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 15, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. 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 $165 
copayment for outpatient diagnostic tests/Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $165 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests/Medicare-covered radiological diagnostic 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 an ultrasound provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an endosteal implant (D6010 x 
4) and bone graft at time of implant placement (D6104 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical placement of an endosteal implant (D6010 x 4) and bone graft at time of implant placement (D6104 x 
4).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehab services provided from July 
1, 2022, to August 30, 2022. 
 
You asked the Plan to waive the copayment for cardiac rehab services. You say that you were told this was 
covered. If you had known you would have such a large copayment, you would not have had these services. 
You cannot afford this bill. 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 cardiac rehabilitation services. You had 16 visits, each having a $10 copayment ($10 x 16 = 
$160). 
 
You have been asked to pay a $160 total copayment for cardiac rehab services. This item/service falls within 
the cardiac 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 cardiac rehab services provided from July 1, 
2022, to August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services (99202) provided on May 16, 2022. 
 
You asked the Plan to pay for procedure code 99202. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a new patient is a patient that has not been seen 
by a physician in the same group of the same specialty within the prior three years. 
 
In this case, the enrollee was seen by the same provider on May 11, 2022, and May 16, 2022. This is not a new 
patient per Medicare rules. Therefore, we decided that the Plan does not have to pay for the office visit services 
(99202) provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x4) 
provided on September 22, 2022. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation - per site (D7953), and 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x4). You say that you 
have damaged teeth and a resulting bone graft due to an accident on June 15, 2022. You also say that the 
services should be covered under your medical plan. The Plan denied your request. The Plan says these 
services are not covered under the benefit package. 
 
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 bone 
replacement graft for ridge preservation - per site (D7953), and extraction, erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210 x4) provided on September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 08, 2022. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services 
provided on September 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) and radiographic images (D0210) 
provided on March 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you called the Plan to make sure the provider 
was in-network. 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. Also, the Plan verified there was no 
contact with the Plan prior to the date of service to verify provider eligibility. 
 
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 oral evaluation (D0150) and radiographic images (D0210) provided on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the caries risk assessment and documentation (D0603) and 
comprehensive oral evaluation (D0150) provided on July 7, 2022. 
 
You asked the Plan to pay for the caries risk assessment and documentation and comprehensive oral evaluation. 
You say that you are allowed free cleanings two times per year. You also say that you did not tell them to do 
anything special that would cost you extra. The Plan denied your request. The Plan says the caries risk 
assessment and documentation is not covered under your plan. The Plan also says that the comprehensive oral 
evaluation does not meet the frequency requirements of 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, the caries risk assessment and 
documentation (D0603) is not among those covered under this benefit. The contract says that comprehensive 
oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received 
a comprehensive oral evaluation (D0150) on January 12, 2021, and your comprehensive oral evaluation 
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the caries 
risk assessment and documentation (D0603) and comprehensive oral evaluation (D0150) provided on July 7, 
2022.