Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary or rest home visit provided on October 07, 2022, 
to October 10, 2022. 
 
You asked the Plan to pay for Domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for Domiciliary or rest 
home visit provided on October 07, 2022, to October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under codes 88312 and 88305 
provided on August 02, 2022. 
 
You asked the Plan to pay for laboratory services billed under codes 88312 and 88305. You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
billed under codes 88312 and 88305 provided on August 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the neurology office visit provided on June 
27, 2022. 
 
You asked the Plan to waive the copayment for the neurology office visit. You say that you don't believe you 
should be charged for this visit. 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 physician services. 
 
You have been asked to pay a $45 copayment for the neurology 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 the neurology office visit provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair broken complete lower denture (D5511) provided on 
September 20, 2022. 
 
You asked the Plan to pay for the dental service. You say that you have not used all of your dental benefit 
amount and would like for the dental service to be 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 the date of service of June 2, 2022. 
Therefore, we decided that the Plan does not have to pay for repair broken complete lower denture (D5511) 
provided on September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on October 10, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you benefit for periodontal services should not 
have been exhausted. 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 15, 2022. On 
June 20, 2022, the Plan paid for periodontal maintenance. On September 15, 2022, the Plan paid for 
periodontal scaling and root planning. Therefore, we decided that the Plan does not have to pay for periodontal 
maintenance (D4910) provided on October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental examination (D0150), and general anesthesia 
(D9222, D9223) provided on September 8, 2022. 
 
You asked the Plan to pay for a dental examination (D0150), and general anesthesia (D9222, D9223). You say 
that you were advised on September 8, 2022, that the extraction and other procedures will be charged a total 
amount of $695, which you paid off. You also say that they sent another bill for the amount of $190.26, which 
you were not aware of, and she wants to appeal due to not having the funds to pay it. The Plan denied your 
request. The Plan says procedure codes for general anesthesia (D9222, D9223) are not covered under your 
benefit plan per the EOC. The Plan also says that the coverage of current procedural terminology (CPT) code 
for a dental examination (D0150) falls under the dental allowable one procedure every three plan years, which 
was already exhausted on July 18, 2022. 
 
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, general anesthesia (D9222, D9223) is 
not among those covered under this benefit. The Plan rules say that they cover one dental examination (D0150) 
every three plan years. The record shows this benefit was exhausted on July 18, 2022. Therefore, we decided 
that the Plan does not have to pay for a dental examination (D0150), and general anesthesia (D9222, D9223) 
provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 29, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. 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 office visit provided on 
June 29, 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 
September 15, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that You say that the coverage 
booklet does not differentiate routine vs diagnostic. You are being charged for a diagnostic exam and you do 
not agree with 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 $40 
copayment for Hearing services. 
 
You have been asked to pay a $40 copayment for specialist office visit. This item/service falls within the 
Hearing services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for specialist office visit 
provided on September 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient rehab stay provided 
from May 4, 2022, to May 9, 2022. 
 
You asked the Plan to waive the copayment for an inpatient rehab stay. You say that you have so many 
copayments for this stay, you cannot afford 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 days 1-7: 
a $175 copayment per day for inpatient hospital care. You were admitted for 5 days, resulting in a $875 
copayment ($175 x 5 days = $875). 
 
You have been asked to pay an $875 copayment for an inpatient rehab 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 copayment for an in-
network inpatient rehab stay provided from May 4, 2022, to May 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
October 26, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that this was routine 
bloodwork and should be covered. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies (laboratory tests). 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies (laboratory tests) 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 laboratory services provided on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a white filling (D2335) for tooth #9 provided on December 
21, 2021. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because white fillings 
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 a white 
filling (D2335) for tooth #9 provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the dental services on October 6, 2022. 
 
You asked the Plan to waive the copayment for dental services. You say that you would like to request 
reconsideration for payment. 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 50% 
coinsurance after $100 deductible for the dental services.  
 
You have been asked to pay a 50% coinsurance after $100 deductible for the dental services. This item/service 
falls within the dental 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 dental 
services on October 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic lab testing provided on February 01, 2022. 
 
You asked the Plan to pay for genetic lab testing. You say that this was medically necessary and should be 
covered. 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 genetic lab testing 
provided on February 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on August 09, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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 lab testing provided on 
August 09, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay provided from 
October 12, 2022, to October 13, 2022. 
 
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that you feel you should not 
be charged for an inpatient stay because this was an emergency room visit and the ER copayment should apply. 
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 $395 
copayment per day for days 1 to 5 for covered hospital care.  
 
You have been asked to pay a $395 copayment for a one-day 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 reduce the copayment for 
an inpatient hospital stay provided from October 12, 2022, to October 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on September 14, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you say that no medication was 
administered during the test; therefore, you should not have to pay the billed amount. 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 $30 
copayment for each outpatient x-ray, diagnostic procedure, and test.  
 
You have been asked to pay $26.64, which is less than the standard $30 copayment for an x-ray. This x-ray 
falls within the Outpatient diagnostic tests and therapeutic services and supplies (PA) 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 x-ray provided on September 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network, acute, inpatient stay 
provided from August 12, 2022, to August 18, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that your mother cannot afford this 
large payment, and that you and your sister did most of the care, as the hospital was short staffed. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $275 copayment per day for days 1 through 6 per benefit period for inpatient hospital care.  
Your mother was in the hospital for 6 days, resulting in a $1,650 total copayment ($275 x 6 days = $1,650) 
 
The enrollee has been asked to pay a $1,650 total copayment for an inpatient stay. This item/service falls 
within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for an in-network, acute, inpatient 
stay provided from August 12, 2022, to August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 5, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you thought it was a routine cleaning and would 
like for the Plan to cover the dental service. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of March 16, 2022. 
Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on 
October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral radiographic images (D0230) provided on October 
31, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service 
because more x-rays were needed. 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 the date of service of October 31, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral radiographic images (D0230) provided 
on October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 22, 2022. 
 
You asked the Plan to pay for the dental service. You say that you went to a new dentist office and your prior 
dentist visit was only for a 6-month exam. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. Also, the prior provider verified the proper billing and 
comprehensive evaluation was done. 
 
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 the date of service of March 1, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on September 22, 2022.