Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for outpatient surgery on February 28, 2023.  
 
You asked the Plan to waive the cost sharing for outpatient surgery. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for each Medicare-covered outpatient hospital facility visit. The provider billed in the amount of 
$9,521.69 and the allowed amount is $4,895.67. The coinsurance is $469.04 for the service. $205.27 + $469.04 
= $674.31. Therefore, results in the total cost sharing amount of $674.31. 
 
You have been asked to pay a $205.27 deductible and a $469.04 coinsurance for outpatient surgery. 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 
cost sharing for outpatient surgery on February 28, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for an office visit on October 27, 2022.  
 
You asked the Plan to waive the coinsurance for an office visit. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for in-network provider and professional 
services at specialists office. Covered services include consultation, diagnosis, and treatment by a specialist. 
 
The Plan says you must pay a $26.44 coinsurance for an office visit. Based on the Plan contract, however, you 
cannot be asked to pay more than a $0 copayment for an office visit. Therefore, we decided that the Plan has to 
waive the coinsurance for an office visit on October 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.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 14, 2023, 
to February 17, 2023.  
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan follows Medicare rules. The rules say that any claim with incomplete, missing, or invalid information 
may be returned as unprocessable. 
 
We looked at the file and the rules. The claim was billed with a type of bill 323. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from February 14, 2023, to February 
17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that this should 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 date of service March 3, 2023. 
Therefore, we decided that the Plan does not have to pre-approve complete denture mandibular (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CGM provided on January 12, 2023. 
 
You asked the Plan to waive the coinsurance for the CGM. You say that you do not agree with the out-of-
pocket amount you were billed. 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 non-OneTouch/LifeScan supplies, including test strips, glucose monitors, solutions, lancets and 
lancing devices, with a medical exception. 
  You have been asked to pay $315, which is 20% of the allowed amount for the CGM. The allowed amount is 
$1,575 (20% x $1,575 = $315). The CGM falls within the diabetes self-management training, diabetic services 
and 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 CGM provided on 
January 12, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for chemotherapy provided on February 7, 
2023. 
 
You asked the Plan to reduce the cost share for chemotherapy. You say that you previously received the same 
services with a lower cost share. 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 each Medicare-covered chemotherapy drug and the administration of that drug and a $250 
copayment for services provided at an outpatient hospital.  
 
You have been asked to pay $1,831.89 for chemotherapy. This total includes 20% of the allowed amount for 
chemotherapy and the administration of the drugs and a $89.90 copayment for outpatient hospital services, 
which is less than the standard $250 copayment. Chemotherapy drugs and the administration of the drugs fall 
within the Medicare Part B Prescription Drug benefit category. Services provided at an outpatient hospital fall 
within Outpatient Surgery and Other Medical 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 reduce 
the cost share for chemotherapy provided on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and 
mandibular partial denture - cast metal framework with resin denture bases (D5214). 
 
You asked the Plan to pre-approve the complete denture - maxillary and mandibular partial denture. 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 complete denture - maxillary and mandibular partial denture was exhausted on date 
of service December 19, 2019.  
 Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and 
mandibular partial denture - cast metal framework with resin denture bases (D5214).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on September 21, 2022. 
 
You asked the Plan to pay for nursing facility care. 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 nursing facility care 
provided on September 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chemotherapy and a specialist visit 
provided on March 1, 2023. 
 
You asked the Plan to waive the copayment for chemotherapy and a specialist visit. You say that you disagree 
with the cost share applied. 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 chemotherapy drugs and a $35 copayment for a specialist visit.  You have been asked to pay $1,339.29 for chemotherapy and a specialist visit. This total includes $1,304.29, 
which is less than the standard coinsurance for chemotherapy drugs and a $35 copayment for a specialist visit. 
The chemotherapy drugs fall within the Medicare Part B Prescription Drugs 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 chemotherapy and a specialist visit provided on March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
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 October 12, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
stopped at an emergency medical transport station as you were having chest pains. You also say that they 
advised that you should be taken by their ambulance to the emergency room, however you declined. 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 October 12, 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 October 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for chemotherapy drugs and the 
administration of the drugs provided on January 16, 2023, to February 24, 2023. 
 
You asked the Plan to reduce the coinsurance for chemotherapy drugs and the administration of the drugs. You 
say that you are on a budget and unable to afford the coinsurance applied for the chemotherapy treatment. 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 Prescription Drugs. 
 
You have been asked to pay 20% coinsurance for chemotherapy drugs and the administration of the drugs. 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 reduce the coinsurance for chemotherapy drugs and the administration of the drugs provided on January 16, 
2023, to February 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation - diagnostic service provided by dentist 
or physician (D9310). 
 
You asked the Plan to pre-approve the consultation - diagnostic service. You say that this should be covered as 
well as the entire process. The Plan denied your request. The Plan says this service is not covered in your 
dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
consultation - diagnostic service provided by dentist or physician (D9310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266 x 2), biologic 
materials to aid in soft and osseous tissue regeneration (D4265), gum surgery (D4266), I.V. sedation - first 15 
minutes (D9239), and sedation each 15 minutes (D9243). 
 
You asked the Plan to pre-approve these dental services. 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 pre-approve 
guided tissue regeneration (D4266 x 2), biologic materials to aid in soft and osseous tissue regeneration (D4265), gum surgery (D4266), I.V. sedation - first 15 minutes (D9239), and sedation each 15 minutes 
(D9243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft tooth #18 (D7953). 
 
You asked the Plan to pre-approve bone replacement graft. 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 pre-approve bone 
replacement graft tooth #18 (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the intraoral-periapical first radiographic 
image (D0220), intraoral-periapical additional radiographic image (D0230), extraction, of an erupted tooth 
requiring removal of bone and/or sectioning of tooth (D7210), bone replacement graftretained natural tooth
first site in quadrant (D4263), custom fabricated abutmentincludes placement (D6057), and an abutment 
supported retainer for a porcelain/ceramic fixed partial denture (D6068) provided from July 19, 2022, through 
December 29, 2022. 
 
  
 
 
You asked the Plan to issue reimbursement for the dental items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the dental 
items/services were received from an out-of-network provider and are not covered by your supplemental 
benefits. Additionally, dental implants are not covered.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received dental items/services from an out-of-network provider. Though the Plan offers 
a dental benefit in excess of Medicare coverage, the items/services provided are not covered under this benefit 
when received from an out-of-network provider. Additionally, dental implants and all related services are not 
covered under the supplemental dental policy. Therefore, we decided that the Plan does not have to issue 
reimbursement for the intraoral-periapical first radiographic image (D0220), intraoral-periapical additional 
radiographic image (D0230), extraction, of an erupted tooth requiring removal of bone and/or sectioning of 
tooth (D7210), bone replacement graftretained natural toothfirst site in quadrant (D4263), custom fabricated 
abutmentincludes placement (D6057), and an abutment supported retainer for a porcelain/ceramic fixed 
partial denture (D6068) provided from July 19, 2022, through December 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 25, 2023. 
 
You asked the Plan to pay for laboratory services. 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 
provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional hearing aid batteries provided on February 24, 
2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.   
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the additional hearing aid batteries provided in this 
case are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
additional hearing aid batteries provided on February 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical extraction (D7210) for tooth #31. 
 
You asked the Plan to pre-approve the dental service. You say that you should not have to pay out of pocket for 
a tooth extraction. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because surgical extractions are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical extraction (D7210) for tooth #31.