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

 
We decided that the Plan does not have to pay for additional intraoral and bitewing x-rays, a periodic oral 
evaluation, and cleaning (D1110, D0120, D0220, D0274, D0230) provided on December 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial and charges. The Plan denied your request. The Plan says your benefit for the x-rays was 
exhausted on the appealed claim. You are also responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider.  
 
 
 
 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 dental x-rays was exhausted on date of service December 6, 2022. 
 
you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
additional intraoral and bitewing x-rays, a periodic oral evaluation, and cleaning (D1110, D0120, D0220, 
D0274, D0230) provided on December 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 29, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell 
and your doctor told you to call the ambulance to assist you with getting up off the floor. You also say that you 
were told to go to urgent care so you walked to your car and drove yourself. 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 November 29, 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 the ambulance response and treatment with no 
transport provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on August 25, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that the enrollee couldnt choose and in-network 
provider. 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 nursing facility care 
provided on August 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the oxygen rental equipment and 
humidifier provided from November 23, 2022, to December 23, 2022. 
 
You asked the Plan to waive the coinsurance for the oxygen rental equipment and humidifier. You say that the 
benefits should not restart because your old device broke. 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 10% 
coinsurance for durable medical equipment and related supplies.  
 
 
 You have been asked to pay $19 coinsurance which is 10% of the allowed amount for the oxygen rental 
equipment provided on November 23, 2022 ($190 allowed amount x 10% = $19). You have also been asked to 
pay $27.40 coinsurance which is 10% of the allowed amount for the humidifier provided on November 23, 
2022 ($274 allowed amount x 10% = $27.40). You have also been asked to pay $19 coinsurance which is 10% 
of the allowed amount for the oxygen rental equipment provided on December 23, 2022 ($190 allowed amount 
x 10% = $19). These items/services fall within the durable medical equipment 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 coinsurance for the oxygen rental equipment and humidifier 
provided from November 23, 2022, to December 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room visit provided on 
November 17, 2022, and the inpatient hospital stay provided from November 21, 2022, to November 30, 2022. 
 
You asked the Plan to waive the copayments for the emergency room visit, and the inpatient hospital stay. You 
say that you have met your maximum out-of-pocket expense. 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 $120 
copayment for emergency care. Your contract with the Plan also clearly says that you must pay a $150 
copayment per day, for days 1 to 7 and a $0 copayment for days 8 to 90 for the inpatient hospital stay. 
 
The record shows you had not met your maximum out-of-pocket amount at the time of service. You have been 
asked to pay a $120 copayment for the emergency room. This item/service falls within the emergency care 
benefit category. You have also been asked to pay a total of a $958.92 copayment, which is less than the 
standard copayment for the inpatient hospital stay. 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 copayments for the emergency room visit 
provided on November 17, 2022, and the inpatient hospital stay provided from November 21, 2022, to 
November 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Keytruda injection and drug 
administration provided on October 20, 2022. 
 
You asked the Plan to waive the coinsurance for the injection and drug administration. You say that you 
disagree with the cost for this service. 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 in-network Medicare Part B drugs.  
 
The records show you met your out-of-pocket maximum during the processing of this claim. You have been 
asked to pay $3,225.16, which is less than the standard 20% coinsurance for the injection and drug 
administration. These items/services fall within the Medicare Part B drugs 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 the Keytruda injection and drug administration provided on October 
20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does not specify any complex functional impairments or active 
medical comorbidities thus the complexity of your documented nursing, medical and rehabilitation needs 
would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the astigmatism-correct function and the presbyopia-correct 
function September 7, 2022, to October 5, 2022. 
 
You asked the Plan to pay for the astigmatism-correct function and the presbyopia-correct function. You say 
that due to your irregular shaped eyes, you needed the other lenses for the cataract surgeries. The Plan denied 
your request. The Plan says the services are not covered benefits. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the 
enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL.  
 
  
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. While a P-C IOL may be appropriate for you, neither the Plan nor Medicare 
covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to 
pay for the astigmatism-correct function and the presbyopia-correct function September 7, 2022, to October 5, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the gammagard injections provided from 
August 1, 2022, to August 29, 2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you were not properly informed of 
the cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the injections. These items/services fall within the Medicare 
Part B prescription drugs benefit category.  
 Date of Service Item Allowed Amount 20% Coinsurance 
August 1, 2022 Gammagard injection $2,699.82 $539.96 
August 2, 2022 Gammagard injection $2,699.82 $539.96 
August 4, 2022 Gammagard injection $2,699.82 $539.96 
August 5 2022 Gammagard injection $2,699.82 $539.96 
August 8, 2022 Gammagard injection $2,699.82 $539.96 
August 15, 2022 Gammagard injection $3,599.76 $719.95 
August 29, 2022 Gammagard injection $3,599.76 $719.95 
 
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 the gammagard injections provided from August 1, 2022, 
to August 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the chemotherapy drugs and the laboratory 
services provided on January 20, 2023. 
 
You asked the Plan to waive the cost share for the chemotherapy drugs and the lab services. You say that you 
hoped the Plan would cover more. 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 Medicare Part B chemotherapy drugs. Your contract with the Plan also clearly says that you must pay a $40 copayment for laboratory services provided at an outpatient hospital. 
 
You have been asked to pay a $40 copayment for lab services provided on January 20, 2023. These 
items/services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 
 
You have been asked to pay 20% coinsurance for the chemotherapy drugs and the lab services. These 
items/services fall within the Medicare Part B prescription drugs benefit category. 
 
Date of Service Code Allowed Amount 20% Coinsurance 
January 20, 2023 0258 $29.00 $5.80 
January 20, 2023 J2469 $310.00 $62.00 
January 20, 2023 J2997 $984.00 $196.80 
January 20, 2023 J8540 $48.00 $9.60 
January 20, 2023 J9358 $5,920.00 $1,184.00 
January 20, 2023 J9358 $5,956.87 $1,191.37 
January 20, 2023 96375 $1,210.00 $242.00 
January 20, 2023 96413 $235.00 $47.00 
 
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 the chemotherapy drugs and the laboratory services provided 
on January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the cystourethroscopy and arthrocentesis 
provided from January 26, 2023, to January 27, 2023. 
 
You asked the Plan to reduce the copayments for the surgical procedures. You say that these procedures should 
not be considered surgery, and the facility should not be considered an outpatient hospital. 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 in-network outpatient surgery at an outpatient hospital.  
 
According to Medicare both procedures (code 52000 and 20610) are considered surgical procedures. The 
records show that the facility where the services were received is considered an outpatient hospital. You have been asked to pay a $250 copayment for each surgical procedure. These items/services fall within the 
outpatient surgery 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 copayments for the 
cystourethroscopy and arthrocentesis provided from January 26, 2023, to January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the onabotulinumtoxina injection and drug 
administration provided from September 21, 2022, to December 20, 2022. 
 
You asked the Plan to waive the cost share for the injection and drug administration. You say that the injections 
did not help so you should not have to pay. 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 in-network Medicare Part B drugs. Your contract with the Plans also clearly says that you must pay a $30 copayment for in-network surgical or other services provided by a specialist. 
 
You have been asked to pay 20% coinsurance for each injection. These items/services fall within the Medicare 
Part B drugs benefit category. You have also been asked to pay a $30 copayment for each drug administration 
service. These items/services fall within the physician/practitioner 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 cost share for the onabotulinumtoxina injection and drug administration provided 
from September 21, 2022, to December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental crown (D2752) provided on September 14, 2022. 
 
You asked the Plan to pay for the dental crown. 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 do not fall 
within your 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 a dental 
crown (D2752) provided on September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on December 13, 2022. 
 
You asked the Plan to pay for the dental 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 do not fall 
within your 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 
occlusal guard (D9944) provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
complete denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee cannot find their last pair and 
they cannot eat without them. 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 July 20, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
complete denture (D5120).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for PT services and a specialist office visit 
provided from November 2, 2022, to November 4, 2022. 
 
You asked the Plan to waive the copayment for PT services and an office visit. You say that you met your 
maximum out-of-pocket and should not owe anything. 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 
copayment for each Physical and speech therapy service and a $35 copayment for physician specialist services.  
 
You have been asked to pay a total copayment of $42.20 for PT services and an office visit. The total for the 
services rendered are less than the standard copayment because your maximum out-of-pocket was met with the 
processing of this claim. The PT services fall within the outpatient rehabilitation services benefit category. The 
specialist visit falls within the physician/practitioner 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 PT services and a specialist office visit provided from November 2, 2022, to 
November 4, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrodes (A4595) provided on September 27, 2022. 
 
You asked the Plan to pay for the supplies. You say that the procedure code used in the case is accepted 
according to the enrollee's Plan's Durable Medical Equipment List. The Plan denied your request. The Plan 
says that the documentation supplied does not support the billed code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record contains a valid physician order, proof of delivery, and relevant medical records which support 
medical necessity for the supplies provided in this case. Therefore, we decided that the Plan has to pay for the 
electrodes (A4595) provided on September 27, 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.