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

 
We decided that the Plan does not have to waive the coinsurance for a hospital outpatient clinic visit, and a 
joint injection provided on July 05, 2023. 
 
You asked the Plan to waive the coinsurance for a hospital outpatient clinic visit, and a joint injection. You say 
that you do not agree with the cost sharing for these 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 20% 
coinsurance for hospital (or outpatient facility) fees for Medicare-covered outpatient hospital services. 
 
You have been asked to pay 20% coinsurance for a hospital outpatient clinic visit, and a joint injection. This item/service falls within the hospital (or outpatient facility) fees for Medicare-covered 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 $94.24 ($471.20 allowed amount x 20% = $94.24). Therefore, we decided that the 
Plan does not have to waive the coinsurance for a hospital outpatient clinic visit, and a joint injection provided 
on July 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography, and nerve conduction studies 
provided on June 20, 2023. 
 
You asked the Plan to pay for needle electromyography, and nerve conduction studies. You say that prior 
authorization is not required. 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 needle 
electromyography, and nerve conduction studies provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease related services provided on June 
01, 2023, to June 02, 2023. 
 
You asked the Plan to pay for the end-stage renal disease related services. 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 end-stage renal 
disease related services provided on June 01, 2023, to June 02, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the ambulance transportation provided on 
July 29, 2023. 
 
You asked the Plan to reduce the coinsurance for the ambulance transportation. You say that you disagree with 
the coinsurance. 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 40% 
coinsurance for out-of-network ambulance services. 
 
You have been asked to pay 40% coinsurance for the ambulance transportation. This item/service falls within 
the out-of-network 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. The total amount you owe is $263.05 ($657.62 x 40% = $263.05). 
Therefore, we decided that the Plan does not have to reduce the coinsurance for the ambulance transportation 
provided on July 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision benign lesion (D7410) provided on April 24, 2023. 
 
You asked the Plan to pay for excision benign lesion. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for excision 
benign lesion (D7410) provided on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and core buildup services for teeth #8 and # 9 
(D2740, D2950) provided on July 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 a crown 
and core buildup services for teeth #8 and # 9 (D2740, D2950) provided on July 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
July 14, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you did not 
receive an ER visit on the date of service at issue and believe the cost share was billed to you incorrectly. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for an emergency room (ER) visit. This item/service falls 
within the emergency 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 
emergency room (ER) visit provided on July 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
July 10, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you do not 
understand why the services provided are not covered without a copayment. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency 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 emergency room 
(ER) visit provided on July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on July 10, 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 local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on June 29, 2023. 
 
You asked the Plan to pay for wound care services. You say that you say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care services 
provided on June 29, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
June 24, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you feel the 
amount the Plan and you were charged is outrageous for the level of services 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 a $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency 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 emergency room 
(ER) visit provided on June 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital observation visit 
provided on July 10, 2023, to July 14, 2023. 
 
You asked the Plan to waive the copayment for an outpatient hospital observation visit. You say that you 
disagree with the copayment applied and believe you were kept in the hospital for unnecessarily. 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 $299 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $299 copayment for an outpatient hospital observation visit. This item/service 
falls within the outpatient hospital observation 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 outpatient hospital observation visit provided on July 10, 2023, to July 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on June 
22, 2023, to June 27, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
cost share applied due to the quality of care 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 a $310 
copayment for inpatient hospital care. 
 
You have been asked to pay a $310 copayment for an 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. You have been asked to pay $1,550 for an inpatient hospital stay ($310 per day x 5 days = 
$1,550). Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital 
stay provided on June 22, 2023, to June 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a positron emission tomography (PET) 
scan provided on June 26, 2023. 
 
You asked the Plan to reduce the copayment for a positron emission tomography (PET) scan. You say that you 
were informed you were only required to pay a $30 deductible for the testing 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 a $100 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $100 copayment for a positron emission tomography (PET) scan. This 
item/service falls within the outpatient diagnostic 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 reduce 
the copayment for a positron emission tomography (PET) scan provided on June 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on July 
14, 2023. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you did not receive 
ambulance transportation on the date of service at issue and believe the cost share was billed to you incorrectly. 
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 $325 
copayment for ambulance services.  
You have been asked to pay a $325 copayment for ambulance transportation. 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 ambulance 
transportation provided on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image, crowns, and core buildup 
services (D0330, D2751, D2950) provided on July 20, 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 your benefit for the requested item or service has 
already been exhausted. Additionally, this benefit does not include core buildup services. 
 
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 April 1, 2022 (D0330, 
D2751). Additionally, this benefit does not include core buildup services. Therefore, we decided that the Plan 
does not have to pay for a panoramic radiographic image, crowns, and core buildup services (D0330, D2751, 
D2950) provided on July 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vascepa.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection performed at an ambulatory 
surgical center provided on July 12, 2023. 
 
You asked the Plan to waive the copayment for an injection performed at an ambulatory surgical center. You 
say that the service provided was not surgical. 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 $350 
copayment for outpatient surgery. 
 
You have been asked to pay a $350 copayment for an injection performed at an ambulatory surgical center. 
This item/service falls 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 waive the 
copayment for an injection performed at an ambulatory surgical center provided on July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional intraoral x-ray (D0230) provided on July 14, 
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 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 14, 2023. Therefore, 
we decided that the Plan does not have to pay for an additional intraoral x-ray (D0230) provided on July 14, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a massage table provided on May 16, 2023. 
 
You asked the Plan to reimburse for a massage table. You say that your physical therapist suggested that you 
look for a massage table to use to continue your exercise regimen at home. The Plan denied your request. The 
Plan says based on your 2023 benefit Plan and the Pick Your Perks program, a massage table is not a 
reimbursable item. The Plan also says that a massage table is not on the list of approved items. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for OTC items. Medicare 
rules also say that Plans may offer as a supplemental benefit health-related items and medications that are 
available without a prescription, and are not covered by Medicare. If the primary purpose of the item or service 
is comfort, cosmetic or daily maintenance, then it is not eligible as a supplemental benefit. Convenience and 
comfort items, as well as cosmetic items (such as skin moisturizers) are specifically listed as not being eligible 
for a supplemental OTC benefit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a massage table  have not been met. Therefore, we decided that the Plan does not have to 
reimburse for a massage table provided on May 16, 2023.