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

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drug, lab 
services and surgery services provided on November 8, 2022, to December 13, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drug, lab services and surgery 
services. 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 20% 
coinsurance for Medicare Part B prescription drug a $25 copayment for outpatient hospital services/lab services 
and a $30 copayment per visit for outpatient hospital services/surgery services.  You have been asked to pay a 20% coinsurance Medicare Part B prescription drug a $25 copayment for lab 
services and a $30 copayment per visit for surgery services. The total allowed amount for prescription drugs 
$2,788.50. You are being asked to pay $557.70 ($2,788.50 x 20% = $557.70). The total amount you are being 
asked to pay the surgery services is $180 ($30 x 6 = $180). The total amount you are being asked to pay for all 
services is $762.70 ($557.70 + $180 + $25 = $762.70). 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 cost share for 
Medicare Part B prescription drug, lab services and surgery services provided on November 8, 2022, to 
December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298 x 2) purchased on 
May 13, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased through the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298 x 2) purchased on May 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (99326) provided on August 1, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. 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 
provided out-of-network. 
 
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 (99326) provided on August 
1, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that you want to see this provider. The 
Plan denied your request. The Plan says you must use setwork providers for services when there are network 
providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan has paid the full $2,000 dental benefit for services provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought your covered cleanings were 
separate from the annual maximum amount. 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 September 1, 2022. 
Therefore, we decided that the Plan has paid the full $2,000 dental services provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and bone graft for 
repair of peri-implant defect  does not include flap entry and closure (D6103) provided on October 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that your health plan told you, you would be 
reimbursed for dental services out-of-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. 
 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 coverage 
for the requested extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including 
elevation of mucoperiosteal flap if indicated (D7210), but only when they are received from an in-network 
provider. Bone graft for repair of peri-implant defect  does not include flap entry and closure (D6103) is not 
covered under the Plans dental benefits. 
 
The record shows you received the requested dental service from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested D7210 is not covered under this benefit 
when received from an out-of-network provider. The requested D6103 is not among those services covered 
under this benefit under any circumstance. Therefore, we decided that the Plan does not have to pay for 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) and bone graft for repair of peri-implant defect  does not include flap 
entry and closure (D6103) provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the cervical spine (72040) provided on 
November 16, 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 x-ray exam of the cervical spine (72040) provided on November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composites (D2331 and D2392) for tooth 
#6, #11, and #12 provided by an out-of-network provider on January 10, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are confident with the care from the 
out-of-network dentist, and you would like the Plan to reduce the cost of the bill. 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. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
record shows the Plan paid for 2 resin-based composites on January 10, 2023; therefore, your benefit for the 
resin-based composite was exhausted on the date of service of January 10, 2023. Therefore, we decided that the 
Plan does not have to pay more for a resin-based composites (D2331 and D2392) for tooth #6, #11, and #12 
provided by an out-of-network provider on January 10, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on September 02, 2022. 
 
You asked the Plan to pay for an eye exam. You say that the enrollee does not have a choice on which provider 
they see. 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 an eye exam provided 
on September 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard  hard appliance, full arch (code D9944) 
provided on November 8, 2022. 
 
You asked the Plan to pay for the occlusal guard. You say that the occlusal guard is a preventive measure of 
further damage to your teeth. You say that without the guard you grind your teeth when sleeping, which affects 
your jaw causing pain and damages your teeth and will result in costly future medical needs. The Plan denied 
your request. The Plan says an occlusal guard is excluded from coverage. 
 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 item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for an occlusal guard  
hard appliance, full arch (code D9944) provided on November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth stimulator (E0748) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a bone growth stimulator. You say that this is necessary for the enrollee. 
The Plan denied your request. The Plan says this service is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. Additionally, the Plan does not cover 
durable medical equipment out-of-network. We found no exception that would require the Plan to pre-approve 
these items/services. Therefore, we decided that the Plan does not have to pre-approve a bone growth 
stimulator (E0748) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided on November 28, 2022. 
 
You asked the Plan to pay for x-ray services. You say that you believe it 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 x-ray services provided 
on November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 04, 2023. 
 
You asked the Plan to pay for the office visit. You say that the records provided support medical necessity. 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 office visit provided 
on January 04, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on October 14, 2022. 
 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that it was 
recommended that you go to the hospital but you decided not to go. The Plan denied your request. The Plan 
says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 14, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment with no 
transport provided on October 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) provided on December 8, 2022. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images. You say that the dental 
office checked with your plan and stated you had 100% coverage for the procedures needed. You also say that 
nothing on your card indicated to you that the dental office was not valid in 2022 and are requesting a one-time 
exception as you assumed the card was valid upon receipt. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. The Plan also confirmed with you that you received the 
benefits information emailed to you which shows what services the Plan provides. 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 
intraoral - complete series of radiographic images (D0210) provided on December 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport service provided on August 30, 2022. 
 
You asked the Plan to pay for the ambulance transport service. You say that you are requesting reconsideration 
of payment for the ambulance services provided. You also say that the procedure codes were billed 
appropriately. The Plan denied your request. The Plan says based on the information received the claim was 
processed correctly 
 
The Plan must follow Medicare rules. Medicare rules say that this includes transportation  including 
transportation by ambulance  to and from another hospital or freestanding facility to receive specialized 
diagnostic or therapeutic services not available at the facility where the patient is an inpatient. 
 
 
 We looked at the file and Medicare rules. The enrollee was a hospital inpatient at the time of service and was 
transported to a separate facility for testing which means this ambulance service is included in the inpatient 
payment and is not separately paid by Medicare. Based on this information, we decided that Medicare rules for 
coverage of the ambulance transport service have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance transport service provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient rehabilitation services provided on October 27, 
2022, to November 04, 2022. 
 
You asked the Plan to pay for inpatient rehabilitation services. You say that you were not aware that the 
providers 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 inpatient rehabilitation 
services provided on October 27, 2022, to November 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite (D2391) provided on December 14, 
2022. 
 
You asked the Plan to pay for resin-based composite. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 resin-
based composite (D2391) provided on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (code D0330) provided on  
January 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware there is a 36-month 
frequency limit on full mouth and panoramic 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 October 6, 2020. Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (code D0330) provided on 
January 12, 2023.