Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy provided on April 11, 
2023, to April 28, 2023. 
 
You asked the Plan to waive the coinsurance for radiation therapy. You say that you say that you have the fee 
for service full network plan meaning all claim would be in your network. 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 outpatient hospital services. 
 
You have been asked to pay 20% coinsurance for radiation therapy. This item/service falls within the outpatient 
hospital 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. The total you owe is $2,047.89 ($10,239.43 allowed amount x 20% = $2,047.89). Therefore, we 
decided that the Plan does not have to waive the coinsurance for radiation therapy provided on April 11, 2023, 
to April 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core in addition to crown tooth #6 
(D2954) provided on May 1, 2023. 
 
You asked the Plan to pay for the prefabricated post and core. You say that your dentist used the same code on 
November 11, 2021 so under your benefit you are not allowed to use that more than once every 5 years. You 
also say that you didn't have any idea about the codes the dentist used so you would like to appeal the denied 
decision and ask for coverage. The Plan denied your request. The Plan says your benefit for the prefabricated 
post and core in addition to crown tooth 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 service was exhausted on date of service November 22, 2021. Therefore, 
we decided that the Plan does not have to pay for a prefabricated post and core in addition to crown tooth #6 
(D2954) provided on May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a gym membership provided on March 27, 2023. 
 
You asked the Plan to reimburse for gym membership. You say that you have not received any notice that the 
policy has changed, in January of this year, to the Plan pays directly to the fitness center. The Plan denied your 
request. The Plan says the Plan is no longer issuing direct-to-member fitness reimbursement checks based on 
submission year. The Plan also says that the Plans fitness benefit coverage now falls under flex card benefits. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when used by the Plans debit/flex card. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the Plan no longer reimburses you, 
but you must use the debit/flex card. Therefore, we decided that the Plan does not have to reimburse for a gym 
membership provided on March 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services, a device evaluation, and a clinic visit 
provided on March 29, 2023. 
 
You asked the Plan to pay for the lab services, a device evaluation, and a clinic visit. You say that you are 
requesting reconsideration of the denied claim. 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 lab services, a device 
evaluation, and a clinic visit provided on March 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Dexcom CGM and supplies provided on March 29, 2023. 
 
You asked the Plan to pay for the Dexcom CGM and supplies. You say that you were told the items would be 
fully 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 $0 for 
Acuu-check monitors. You must pay 20% coinsurance for blood glucose monitors from all other 
manufacturers. 
  You have been asked to pay $153.01 for a Dexcom CGM and supplies. The total amount allowed to be billed 
for the CGM provided was $765.03. You have been asked to pay a $153.01 coinsurance for these items, which 
is 20% of the allowed amount. This item/service falls 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 pay for the Dexcom CGM and supplies provided on 
March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on May 15, 2023. 
 
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 core 
buildup services (D2950) provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor (99203) provided 
on March 13, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that this is a covered benefit. The Plan denied 
your request. The Plan says these chiropractic services are excluded from coverage. 
 
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 office visit provided by a chiropractor (99203) provided on March 13, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a chemotherapy drug injection and the 
associated administration of the drug provided on September 22, 2022, provided by an OON provider. 
 You asked the Plan to reduce the coinsurance for a chemotherapy drug injection and the associated 
administration of the drug. You say that you disagree with the increased cost share applied to the injection 
received. 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 25% 
coinsurance for Medicare Part B chemotherapy drug injection and 25% coinsurance for the administration of 
the chemotherapy drug when provided by an OON provider.  
 
You have been asked to pay a total coinsurance of $1,144.22 for a chemotherapy drug injection and the 
associated administration of the drug. This total includes $1,125.14, which is 25% of the allowed amount for 
the chemotherapy drug injection ($4,055.55 allowed x 25% = $1,125), and $19.08, which is 25% of the 
allowed amount for the administration of the drug ($76.34 allowed x $25% = $19.08). This item/service falls 
within the Medicare Part B prescription drug 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 coinsurance 
for a chemotherapy drug injection and the associated administration of the drug provided on September 22, 
2022, provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for the evaluation and management provided on 
January 10, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for home visit for the evaluation and management. You say that you are requesting 
reconsideration. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
covered.   
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home visit for the evaluation and management 
provided on January 10, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a gym membership provided from February 1, 2023, to 
March 1, 2023. 
 
You asked the Plan to reimburse for a gym membership. You say that you were not given instructions when 
you first signed up on how to use the benefit. You also say you feel you should be reimbursed for benefits you 
are entitled to. The Plan denied your request. The Plan says this fitness facility is in-network and not eligible 
for reimbursement. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan reimburses gym 
benefits only when the service is obtained through a non-participating fitness clubs and exercise centers. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the gym membership you are 
requesting reimbursement for is in-network. The Plan rules say clearly say that the Plan vendor provides an 
annual reimbursement allowance towards paid memberships at non-participating fitness clubs and exercise 
centers. Therefore, we decided that the Plan does not have to reimburse for a gym membership provided from 
February 1, 2023, to March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) and scaling in presence of 
generalized gingival inflammation (D4346) provided on May 4, 2023. 
 
You asked the Plan to pay for D4921 and D4346. You say that you would like to be fully compensated. The 
Plan denied your request. The Plan says the rendered services have been processed correctly. 
 
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, D4921 is not among those covered 
under this benefit. A $25 copayment has been correctly applied to D4346. Therefore, we decided that the Plan 
does not have to pay for gingival irrigation (D4921) and scaling in presence of generalized gingival 
inflammation (D4346) provided on May 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 9, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 
items/services 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 the lab services provided on March 9, 2023, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that an extended SNF stay should be covered because 
more therapy is needed. The Plan denied your request. The Plan says the enrollee no longer meets the criteria 
for SNF services.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee doesn't have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee doesn't have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee 
doesn't require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on May 18, 2023. 
 
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 core 
buildup services (D2950) provided on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on April 18, 2023. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you thought there would only be a 
$45 copayment, so the additional charge is very surprising and disappointing. 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 injection.  
 
 
 You have been asked to pay $92.64, which is 20% of the allowed amount for a drug injection ($463.20 allowed 
x 20% = $92.64). This item/service falls within the Medicare Part B prescription 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 an injection provided on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) 
provided on April 12, 2023. 
 
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 the 
localized delivery of antimicrobial agents (D4381) provided on April 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair and accessories to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the enrollee is aware 
that the provider is out-of-network. The Plan denied your request. The Plan says enrollees must receive their 
care from a network provider. 
 
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 
the power wheelchair and accessories to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound provided on March 3, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the ultrasound. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the ultrasound provided on March 3, 2023, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, bitewing x-rays, and cleanings 
(D1110, D0274, D0120) provided on May 24, 2023. 
 
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 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 a periodic oral evaluation, bitewing x-rays, and cleanings (D1110, D0274, D0120) provided on May 
24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0220, D0230) provided on March 24, 
2023. 
 
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 intraoral 
x-rays (D0220, D0230) provided on March 24, 2023.