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

 
We decided that the Plan does not have to pay more for periodic oral evaluation - established patient (D0120) 
and prophylaxis - adult (D1110) provided on February 1, 2023. 
 
You asked the Plan to pay more for dental services. You say that you would like services paid 100% by your 
insurance because you feel you were provided incorrect information. The Plan denied your request. The Plan 
says the coinsurance was applied 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. Enrollees must pay 50% of the 
total allowed amount for all routine (preventive and comprehensive) dental services. 
 
The allowed amounts of the covered dental services total $179, resulting in a coinsurance amount of $89.50 
and a Plan payment of $89.50. 
 
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 more for periodic oral evaluation - established patient (D0120) and 
prophylaxis - adult (D1110) provided on February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on January 
09, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care visits. You say that the records attached support 
the services provided. 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 subsequent nursing 
facility care visits provided on January 09, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) of the chest. 
 
You asked the Plan to pre-approve the CT of the chest. You say that the services are medically necessary for 
the enrollee. The Plan denied your request. The Plan says that this service is only supported once per six 
months for three years after the enrollees disease was found, then once a year after that. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 the CT of the chest. Our reviewer says 
that the CT scan is medically necessary. Our physician reviewer found the enrollee has a history of stage 
adenocarcinoma of the right lung treated by resection and chemotherapy in 2018. The enrollee has been having 
CT surveillance scans every 6 months with no sign of recurrence since then. The enrollee's original tumor was 
poorly differentiated and considered high risk by tumor board specialists.  It is the nature of their original tumor 
that is of greatest concern at this point in time and since they are considered very high risk the request for a 6-
month surveillance CT is reasonable and should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT of the chest have been met. Therefore, we decided that the Plan has to 
pre-approve a computed tomography (CT) of the chest.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the ultrasound provided on September 28, 
2022. 
 
You asked the Plan to reduce the deductible for the ultrasound. You say that you should not have to pay 40% of 
the bill. 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. Your 
contract with the Plan says that there is a $400 deductible which applies to outpatient diagnostic tests and 
therapeutic supplies. Your contract with the Plan also says that there is a $0 copayment for outpatient 
diagnostic tests and procedures. The deductible applies. 
 
 
 You have been asked to pay $133.15 towards the deductible for the ultrasound. The item or service you asked 
the Plan to waive the deductible for falls within the outpatient diagnostic tests and therapeutic supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 
deductible which applies to outpatient diagnostic tests and therapeutic supplies. This cost sharing is a 
contractual obligation that had not been met at the time the ultrasound was received on September 28, 2022. 
Therefore, we decided that the Plan does not have to reduce the deductible for the ultrasound provided on 
September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120) 
provided on February 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that your benefit changed after the new year 2023. 
The Plan denied your request. The Plan says your benefit for periodic oral evaluation 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 periodic oral evaluation was exhausted on date of service August 1, 2022.  Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation - established patient 
(D0120) provided on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the specialist office visit and the lesion 
removal surgery provided on September 21, 2022. 
 
You asked the Plan to reduce the deductible for the specialist office visit and the lesion removal surgery. You 
say that you paid $25 for this service in the past. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to out-of-network 
physician/practitioner services, including doctors office visits. Your contract with the Plan also says that there 
is a $55 copayment once the deductible has been met for each out-of-network Medicare-covered specialist 
visit. Your contract with the Plan also says that there is 8% coinsurance once the deductible has been met for 
each out-of-network Medicare-covered outpatient surgery. 
 
You have been asked to pay $91.97 towards your deductible for the specialist office visit. The item or service 
you asked the Plan to waive the deductible for falls within the physician/practitioner services, including 
doctors office visits benefit category. You have also been asked to pay $150.97 towards your deductible for 
the lesion removal surgery. The item or service you asked the Plan to waive the deductible for falls within the 
outpatient surgery, including services provided at hospital outpatient facilities benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to 
physician/practitioner services, including doctors office visits. This cost sharing is a contractual obligation that 
had not been met at the time the specialist office visit and the lesion removal surgery was received on 
September 21, 2022. Therefore, we decided that the Plan does not have to reduce the deductible for the 
specialist office visit and the lesion removal surgery provided on September 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 09, 2022, to 
September 11, 2022. 
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. 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 an office visit provided 
on September 09, 2022, to September 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit with a laboratory draw provided on September 
07, 2022. 
 
You asked the Plan to pay for an office visit with a laboratory draw. 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 an office visit with a 
laboratory draw provided on September 07, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for cancer immunotherapy infusions provided 
from October 4, 2021, to January 16, 2023. 
 
You asked the Plan to waive the cost share for cancer immunotherapy infusions. You say that you did not 
realize there would be a charge and thought the services would 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 20% 
coinsurance for intravenous, subcutaneous, and biological Part B drugs and a $40 copayment for each specialty 
physician visit.  
 
You have been asked to pay $12,769.32 for cancer immunotherapy infusions and specialty physician visits.  
 
Date of Service Service Amount per 
Contract 
Amount Allowed Amount Owed 
October 4, 2021 Injection (J9271) 20% coinsurance $21,101.60 $4,220.32 
October 4, 2021 Specialty Physician Visit  $40 copayment $138.23 $40 
February 14, 2022 Injection (J9271) 20% coinsurance $16,736.00 $4,184.00 
January 16, 2023 Injection (J9271) 20% coinsurance $16,937.00 $4,285.00 
January 16, 2023 Specialty Physician Visit  $40 copayment $124.52 $40 
Total    $12,769.32 
 
The injection falls within the Medicare Part B prescription drugs benefit category. The specialty physician 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 
cost share for cancer immunotherapy infusions provided from October 4, 2021, to January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visits provided on 
December 28, 2022, and January 16, 2023. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that you only had your 
bandages changed and should not have to pay for it. 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 2022 contract with the Plan clearly says that you must pay a 
$15 copayment for each specialist office visit. Your 2023 contract with the Plan also clearly says that you must pay a $15 copayment for each specialist office visit 
 
You have been asked to pay a $15 copayment for each specialist office visit. These items/services fall within 
the physician/practitioner services benefit category. You have been asked to pay a total of $30 ($15 copayment 
+ $15 copayment = $30). This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for the specialist office visits 
provided on December 28, 2022, and January 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical laminectomy and inpatient hospital admission. 
 
You asked the Plan to pre-approve cervical laminectomy and inpatient hospital admission. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 cervical laminectomy and inpatient 
hospital admission. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no documentation of an adequate 
trial an failure of recent physical therapy. More conservative measures are needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cervical laminectomy and inpatient hospital admission have not been met. 
Therefore, we decided that the Plan does not have to pre-approve cervical laminectomy and inpatient hospital 
admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth specialist visit provided on 
April 29, 2022. 
 
You asked the Plan to waive the copayment for the telehealth specialist visit. You say that there were issues 
and you could not use the video conferencing system. 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 $5 
copayment for in-network specialist office visits, including telehealth. 
 
You have been asked to pay a $5 copayment for the telehealth specialist visit. This item/service falls within the 
in-network specialist office visits, including telehealth 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 records show you were seen by a specialist on April 29, 
2022. Therefore, we decided that the Plan does not have to waive the copayment for the telehealth specialist 
visit provided on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on 
February 7, 2023. 
 
You asked the Plan to pay for dental services. You say that this should be paid since the panoramic x ray was 
needed before surgery could be scheduled. The Plan denied your request. The Plan says this service is not 
covered under your 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. Panoramic radiographic image 
(D0330) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0330 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for panoramic 
radiographic image (D0330) provided on February 7, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the shoulder x-ray provided on June 29, 
2022. 
 
You asked the Plan to waive the copayment for the shoulder x-ray. You say that the Plan paid nothing for this, 
and you were left with 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 $50 
copayment for in-network diagnostic tests, including x-rays. 
 
You have been asked to pay a $50 copayment for the shoulder x-ray. This item/service falls within the in-
network diagnostic tests, including x-rays 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. However, since the allowed amount is less than the standard copayment, 
you only owe $43.51. Therefore, we decided that the Plan does not have to waive the copayment for the 
shoulder x-ray provided on June 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the transthoracic echocardiogram provided 
on December 02, 2022. 
 
You asked the Plan to waive the copayment for the transthoracic echocardiogram. You say that you did not 
know the cost share depends on where services are provided. 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 $175 
copayment for in-network diagnostic tests provided by an outpatient hospital. 
 
You have been asked to pay a $175 copayment for the transthoracic echocardiogram. This item/service falls 
within the in-network diagnostic tests provided by an outpatient hospital 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 transthoracic echocardiogram provided on December 02, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on November 17, 
2022. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. 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 an outpatient mental 
health visit provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting a reconsideration of the denied 
charges. 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 an office visit provided 
on January 10, 2023.