Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) provided on 
September 9, 2022. 
 
You asked the Plan to pay for a custom fabricated abutment. You say that you needed these services. The Plan 
denied your request. The Plan says the denied 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 a custom 
fabricated abutment (D6057) provided on September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant replacement (D6091), and scaling and 
debridement (D6081). 
 
You asked the Plan to pre-approve implant replacement and scaling and debridement. You say that these 
services are medically necessary. The Plan denied your request. The Plan says these services have been 
correctly denied. 
 
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 
implant replacement (D6091), and scaling and debridement (D6081).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are requesting reconsideration of approval 
for orthoses services due to abnormalities of gait and mobility. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued skilled nursing facility care.. You say that it would be unsafe to 
discharge the enrollee as they are currently receiving care for the wound on their leg. The Plan denied your 
request. The Plan says 20 additional days between January 13, 2022, and February 2, 2022, were approved, 
which exhausted the benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from January 27, 
2022, through February 2, 2023.There was not a 60-day break, and the Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve continued SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
September 10, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the service were 
medically necessary. 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 $290 
copayment for ambulance services. 
 
You have been asked to pay a $290 copayment for the ambulance services. 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 the ambulance 
services provided on September 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous (D7950), biological material (D4265), and a guided 
tissue regeneration (D4266), provided on July 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendered dental services are not covered. 
 
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 osseous 
(D7950), biological material (D4265), and a guided tissue regeneration (D4266), provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the flu vaccination provided on November 1, 2022. 
 
You asked the Plan to waive the copayment for the vaccination. You say that you think the cost sharing should 
be lower. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is no coinsurance, copayment, or deductible for the pneumonia, influenza, 
Hepatitis B, and COVID-19 vaccines when received in-network. 
 
The Plan says you must pay a $50 copayment for the vaccination. Based on the Plan contract, however, you 
cannot be asked to pay any cost sharing for an in-network influenza vaccination. Therefore, we decided that the 
Plan has to waive the copayment for the flu vaccination provided on November 1, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950), a crown-porcelain/ceramic (D2740), and endodontic therapy (D3310). 
 
You asked the Plan to pre-approve the dental services. You say that you want to know why the Plan doesn't pay 
for the dental services you need. You say you don't have that type of money. The Plan denied your request. The 
Plan says the services are denied as not covered. 
 
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 core 
buildup, including any pins when required (D2950), a crown-porcelain/ceramic (D2740), and endodontic 
therapy (D3310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, lenses and shipping costs billed on October 17, 
2022. 
 
 You asked the Plan to pay for the frames, lenses and shipping costs. You say that you are requesting 
reimbursement for the glasses you purchased after seeing your in-network eyecare provider. The Plan denied 
your request. The Plan says the frames and lenses were purchased from a provider that is not part of the Plan's 
vision network. The Plan also says that shipping charges are not medical in nature and are not covered by the 
Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers frames and lenses when purchased through the Plans vision providers. Shipping 
charges are not medical in nature and are not covered by the Plan. 
 
We looked at the file and the Plan's rules. The record shows you received frames and lenses from an out-of-
network vision provider. Based on this information, we decided that the Plan's rules for coverage of the frames, 
lenses and shipping costs have not been met. Therefore, we decided that the Plan does not have to pay for the 
frames, lenses and shipping costs billed on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 01, 2022. 
 
You asked the Plan to pay for the office visit. You say that the patient moved to Wisconsin and was 
establishing care. 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 September 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral 
imaging (D0210) provided on October 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 13, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an 
intraoral imaging (D0210) provided on October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care on September 06, 2022, to 
October 03, 2022. 
 
You asked the Plan to waive the copayment for wound care. You say that you want to appeal the amount being 
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 $250 
copayment for each Medicare-covered visit to an outpatient hospital facility. If you are having surgery in a 
hospital facility, you should check with your provider about whether you will be an inpatient or outpatient. 
Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay 
the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be 
considered an outpatient. There were five visits. 5 x $250 = $1,250. Therefore, results in the total cost 
sharing amount of $1,250. 
 
 You have been asked to pay a $250 copayment for each wound care. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 wound care on September 06, 
2022, to October 03, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic colonoscopy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a diagnostic colonoscopy. You say that this is medically needed, and you 
are sending medical document to help get it approved. The Plan denied your request. The Plan says There was 
no preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 
a diagnostic colonoscopy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to high noble metal 
tooth #6 (D2750). 
 
You asked the Plan to pre-approve the retainer crown - porcelain fused to high noble metal tooth #6 (D2750). 
You say that you are asking the Plan to provide coverage for a root canal and dental crown (D2750) by an oral 
surgeon. You also say that you were able to have the dental practice provide the service, but the Plan denied 
your request. The Plan denied your request. The Plan says your request for authorization for the retainer crown 
with an oral surgeon is a non-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 when provided by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve a retainer crown - porcelain fused to high noble metal tooth #6 (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the continuous positive airway pressure 
(CPAP) equipment provided on September 14, 2022, and October 14, 2022. 
 
You asked the Plan to waive the cost sharing for the continuous positive airway pressure (CPAP) equipment. 
You say that you did not previously have a cost share for these items/services. 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 covered items and related supplies, which includes oxygen equipment. 
 
You have been asked to pay a cost share of $88 for the continuous positive airway pressure (CPAP) equipment 
($440 allowed amount x .20 = $88). These items/services fall within the durable medical equipment (DME) 
and related 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 cost sharing for the continuous 
positive airway pressure (CPAP) equipment provided on September 14, 2022, and October 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
September 8, 2022, to September 11, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you thought there was no 
charge since you were admitted. 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 $475 
copayment per day for days 1-4 for inpatient hospital care.  
 
 
  The file shows that you were hospitalized from September 8, 2022, to September 11, 2022. Since there is no 
copayment for the discharge date, you have been asked to pay a $475 copayment per day for days 1-3 for the 
inpatient care. The total you owe is $1,425 ($475 copayment x 3 days = $1,425). This item/service falls within 
the inpatient hospital 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 inpatient 
hospital care provided from September 8, 2022, to September 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each office visit provided on March 25, 
2022, to September 27, 2022. 
 
You asked the Plan to waive the copayment for each office visit. You say that you feel that you should not have 
to pay 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for each office visit. This item/service falls within the 
physician/practitioner services, including doctors 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 each office visit provided on March 25, 2022, to September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on October 27, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 dental services provided on October 27, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) for tooth #29 provided on November 
10, 2022. 
 
You asked the Plan to pay for the dental service. You say that it was medically necessary for you to get the 
extraction done. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because extractions 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
extraction (D7210) for tooth #29 provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate mandibular denture (D5140). 
 
You asked the Plan to pre-approve the dental services. You say that your partial denture broke. 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 28, 2019. 
Therefore, we decided that the Plan does not have to pre-approve an immediate mandibular denture (D5140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on November 2, 2022. 
 
You asked the Plan to pay for an occlusal guard. You say that this helps with bite issues. The Plan denied your 
request. The Plan says this 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 an 
occlusal guard (D9944) provided on November 2, 2022.