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

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on May 24, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you fell a could not get up, 
and did not have control where you went. 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 ambulance services. 
 
You have been asked to pay a $250 copayment for an ambulance ride. 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 an ambulance ride 
provided on May 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a vein ultrasound provided on June 20, 
2022. 
 
You asked the Plan to waive the copayment for a vein ultrasound. You say that this should only be a $15 
copay. The $100 must be a mistake. 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 $115 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $115 copayment for a vein 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 a vein ultrasound provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and an intraoral - 
periapical first x-ray (D0220) provided from June 7, 2022, to July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are 72 years old, and you are just trying to 
live. You also say that you thought Medicare would pay for what was not 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 The member already 
received intraoral-periapical first radiographic image on 03/30/2022, and a comprehensive oral evaluation 
(D0150) on March 15, 2022. Therefore, we decided that the Plan does not have to pay for comprehensive oral 
evaluation (D0150) and an intraoral - periapical first x-ray (D0220) provided from June 7, 2022, to July 19, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on March 18, 2022. 
 
You asked the Plan to waive the copayment for MRI. 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 $150 
copayment for Outpatient diagnostic tests/Medicare-covered service.  
 
You have been asked to pay a $150 copayment for MRI. This item/service falls within the Outpatient 
diagnostic tests/Medicare-covered service 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 magnetic resonance imaging (MRI) provided on March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified fixed prosthodontic procedure (D6999) 
provided on April 21, 2022. 
 
You asked the Plan to pay for the prosthodontic procedure. You say that you disagree with the denial for the 
prosthodontic procedure. The Plan denied your request. The Plan says an unspecified fixed prosthodontic 
procedure (D6999) is not covered by the enrollee'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 pay for an 
unspecified fixed prosthodontic procedure (D6999) provided on April 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on May 2, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the coinsurance. 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 durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount for the DME is $651.14. 
The amount you are being asked to pay is $130.23 ($651.14 x 20% = $130.23). 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 (DME) provided on May 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on June 09, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you shouldnt have to pay for 
this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Outpatient surgery in a hospital outpatient facility. 
 
You have been asked to pay a $250 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in a hospital outpatient 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.You have been asked to pay $120.07 which is less than the 
standard $250 copayment for outpatient surgery. Therefore, we decided that the Plan does not have to waive 
the copayment for outpatient surgery provided on June 09, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 31, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollees network primary care physician (PCP) or plan must give the 
enrollee approval in advance before they can use providers not in the plan's network. This is called giving them 
a "referral." 
 
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 home health services provided on December 31, 
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 intraoral - periapical first radiographic image (D0220) for 
teeth numbers 4, 5, 12, 13, 15, 17, and 32, comprehensive oral evaluation (D0150), panoramic radiographic 
image (D0330), and an unspecified adjunctive procedure (D9999) provided on March 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to the office and were told the Plan 
covers the x-rays for the visit and services. 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 intraoral - periapical first radiographic image (D0220) for teeth numbers 4, 5, 12, 13, 15, 17, and 32, 
comprehensive oral evaluation (D0150), panoramic radiographic image (D0330), and an unspecified adjunctive 
procedure (D9999) provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on July 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that you would be 
receiving periodontal maintenance. You say that you thought you were getting a regular cleaning. 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 March 1, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive evaluation (D0180) and the oral hygiene 
instructions (D1330) provided on August 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the extraction would be covered. 
The Plan denied your request. The Plan says your benefit for the comprehensive evaluation has already been 
exhausted. Also, the denial of payment for the oral hygiene instructions 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 comprehensive evaluation was exhausted on the date of service of July 28, 2022. 
The oral hygiene instructions are not covered under the dental benefit. Also, the explanation of benefits shows 
that the extraction (D7210) for tooth #7 was paid on September 4, 2022.  Therefore, we decided that the Plan 
does not have to pay for a comprehensive evaluation (D0180) and the oral hygiene instructions (D1330) 
provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) Tooth #12 and 13 
provided on March 30, 2022. 
 
You asked the Plan to pay for dental services. You say that you want to maintain the health of your teeth, so 
you should not have to pay for services received. The Plan denied your request. The Plan says the service is 
covered but limitations apply. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes crown - 
porcelain/ceramic (D2740) for treatment of carious lesions (visible destruction of hard tooth structure resulting 
from the process of removing dental decay) or fracture resulting in significant loss of tooth structure (e.g., 
missing cusps or broken incisal edge). 
 
  We looked at the file, the Plans rules, and Medicares rules. Benefits for the crowns (D2740) provided due to 
wear and erosion (wear and erosion is not covered by any Delta Dental plan) is not covered under this Plan.  
Therefore, we decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) Tooth #12 and 
13 provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on April 20, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for dermatology services. You say that the records support the services. The Plan 
denied your request. The Plan says there is no prior authorization on file. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for dermatology services provided on April 20, 2022, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy provided on September 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient therapy. You say that these services were medically necessary. The 
Plan denied your request. The Plan says there is no prior authorization on file for these services. 
 
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 outpatient therapy provided on September 2, 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 facial photographic images (D0350) and the oral hygiene 
instructions (D1330) provided on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not told that the dental services would 
not be covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the facial photographic images and the oral hygiene instructions 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. 
 
  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 facial 
photographic images (D0350) and the oral hygiene instructions (D1330) provided on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on May 23, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you shouldnt have to pay 
for this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for Specialist office visits. 
 
You have been asked to pay a $45 copayment for specialist office visit. This item/service falls within the 
Specialist 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 
office visit provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 01, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 office visit provided on August 01, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital stay provided on 
February 03, 2022, to April 06, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital stay. You say that you were told anything 
COVID-19 related 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 Out of network Provider and Professional Services. 
 
You have been asked to pay 20% coinsurance for inpatient hospital stay. This item/service falls within the Out 
of network Provider and Professional 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 inpatient hospital stay provided on February 03, 2022, to April 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network Medicare Part B 
prescription drugs and an out-of-network outpatient office visit provided on August 2, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs and outpatient office visit. 
You say that you disagree with the coinsurance. 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% 
coinsurance for out-of-network Medicare Part B prescription drugs and a 40% coinsurance and out-of-network 
physician/practitioner services.  
 
You have been asked to pay a 40% coinsurance for Medicare Part B prescription drugs and a 40% coinsurance 
and outpatient office visit. The total allowed amount for the prescription drugs is $56.65. The amount you are being asked to pay is $22.66 ($56.65 x 40% = $22.66). The total allowed amount for the office visit is $122.05. 
The amount you are being asked to pay $48.82 ($122.05 x 40% = $48.82). 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 out-of-network Medicare Part B prescription drugs and an out-of-network 
outpatient office visit provided on August 2, 2022.