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

 
We decided that the Plan does not have to pay for a nursing facility visit provided on March 28, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain authorization. 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 a nursing facility visit 
provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an intraoral - periapical first radiographic image 
(D0220) and limited oral evaluation - problem focused (D0140) provided on March 8, 2023. We also decided 
that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220) and limited oral 
evaluation - problem focused (D0140) provided on April 5, 2023. We also decided that the Plan does not have 
to waive the cost share for an extraction, erupted tooth or exposed root provided on April 12, 2023. 
 
You asked the Plan to pay more for the intraoral - periapical first radiographic image and limited oral 
evaluation - problem focused provided on March 8, 2023. You also asked the Plan to pay for the intraoral - 
periapical first radiographic image (D0220) and limited oral evaluation - problem focused (D0140) provided on 
April 5, 2023. You also asked the Plan to waive the cost share for the extraction, erupted tooth or exposed root 
provided on April 12, 2023. You say that you had extra coverage and should not be responsible. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 an intraoral - periapical first radiographic 
image (D0220) and limited oral evaluation - problem focused (D0140) provided on March 8, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral - periapical first radiographic image and limited oral evaluation - problem 
focused was exhausted on date of service March 8, 2023. Therefore, we decided that the Plan does not have to 
pay for an intraoral - periapical first radiographic image (D0220) and limited oral evaluation - problem focused 
(D0140) provided on April 5, 2023.  
 
You have been asked to pay for the extraction provided on April 12, 2023. This service falls within the 
extractions (pulling teeth)  frequency/limitations 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 an extraction, erupted tooth or exposed root provided on April 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on January 26, 2023. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
will not be paying this bill, as you had terrible service from this provider and left without 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 a $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for an in-network 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 in-network emergency room (ER) visit provided on January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on March 08, 2023, to March 22, 
2023. 
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 a home visit provided on 
March 08, 2023, to March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thyroid genomic testing provided on March 29, 2023. 
 
You asked the Plan to pay for thyroid genomic testing. You say that this testing was 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 thyroid genomic testing 
provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on Mar 25, 2023, to 
March 28, 2023.  
 
You asked the Plan to waive the copayment for inpatient hospital stay. 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 $395 
copayment per day for days 1-4 for inpatient hospital care. Includes inpatient acute, inpatient rehabilitation, 
long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you 
are formally admitted to the hospital with a doctors order. The day before you are discharged is your last 
inpatient day. There were three days. 3 x $395 = $1,185. Therefore, results in the total cost sharing amount of 
$1,185. You have been asked to pay a $395 copayment per day for inpatient hospital stay. This item/service falls within 
the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient 
hospital stay on Mar 25, 2023, to March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5211) and a partial lower 
denture (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that you need to get the partial dentures done 
and you been dealing with the problem for months. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the partial dentures 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial upper denture (D5211) and a partial lower denture (D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on April 19, 2023.  
 
You asked the Plan to pay for foot orthotics. You say that the items should be covered by your insurance. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on April 19, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110) provided on May 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe this service should be covered, 
because you feel the 12 months should start at your new enrollment year. 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. This benefit includes the 
requested item or service but is limited to two every 12 months. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered prophylaxis - adult (D1110) on dates of service May 26, 2022, and November 21, 
2022. Therefore, this benefit has been exhausted as of May 22, 2023. Therefore, we decided that the Plan does 
not have to pay for prophylaxis - adult (D1110) provided on May 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport services provided 
on April 15, 2023.  
 
You asked the Plan to waive the copayment for the ambulance transport services. You say that you were 
admitted as inpatient based on the services rendered and would like the copayment removed. The Plan denied 
your request. The Plan says this cost sharing was charged correctly as the authorization on file was approved as 
observation. 
 
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 Medicare-covered ground ambulance benefits. Waived if admitted.  
 You have been asked to pay a $175 copayment for the ambulance transport services. This service falls within 
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 the ambulance 
transport services provided on April 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a myocardial perfusion imaging and a 
regadenoson injection provided on May 17, 2023. 
 
You asked the Plan to reduce the cost share for a myocardial perfusion imaging and an injection. You say that 
you were quoted a $45 copayment for this service. 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 each Medicare-covered radiology service. Your contract with the Plan also clearly says that you 
must pay 20% coinsurance for each Medicare-covered Part B drugs. 
 
You have been asked to pay a $350 copayment for a myocardial perfusion imaging. This item/service falls 
within the outpatient diagnostic tests and therapeutic 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.  
 
You have also been asked to pay $49.59, which is 20% coinsurance of the allowed amount for the injection 
($247.96 allowed amount x 20% = $49.59). 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 cost share for a myocardial perfusion imaging 
and a regadenoson injection provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management provided on November 16, 2022. 
 
You asked the Plan to pay for pain management. 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 pain management 
provided on November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and 
prefabricated post core in addition to crown (D2954). The Plan does not have to pay more for endodontic 
therapy, premolar tooth (excluding final restoration) (D3320) provided on May 9, 2023. 
 
You asked the Plan to the dental services. You say that the services you received should be covered because 
you have $4,000 annual maximum. 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. This benefit includes the 
requested item or service but is limited to $2,000 combined in-network and out-of-network benefit maximum. 
Oral examination  one per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received a covered periodic oral evaluation - established patient (D0120) on date of service January 
3, 2023. Although these are two different services, they fall within the same category in your Evidence of 
Coverage and are subject to the same frequency limitations. Therefore, this benefit has been exhausted as of 
May 9, 2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem 
focused (D0140). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $406 on date of service January 11, 2023, $79 on date of service March 30, 2023, $772.72 
on date of service April 19, 2023, and $742.28 on date of service May 9, 2023 ($406 + $79 + $772.72 + 
$742.28 = $2,000). Therefore, this benefit has been exhausted as of May 9, 2023. Therefore, we decided that 
the Plan does not have to pay for prefabricated post and core in addition to crown (D2954) and the Plan does 
not have to pay more for endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided on 
May 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the ambulance services provided on April 
20, 2023, the wrist fracture procedure provided on May 2, 2023, and the wrist x-ray, and the wrist brace 
provided on May 18, 2023. 
 
You asked the Plan to waive the cost sharing for the ambulance services, the wrist fracture procedure, the wrist 
x-ray, and the wrist brace. You say that you are on a limited income each month. 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 $250 
copayment per one-way ambulance trip, a $20 copayment for x-rays and ultrasounds, a $325 copayment for 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers, 
and a 20% coinsurance for all other prosthetic medical supplies which includes braces.  
 
You have been asked to pay a $250 copayment for the ambulance services. These items/services fall within the 
ambulance services benefit category. You have been asked to pay a $325 copayment for the wrist fracture 
procedure. This item/service falls within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. You have been asked to pay a $20 
copayment for the wrist x-ray. This item/service falls within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. You have also been asked to pay a $52.48 coinsurance for the wrist 
brace ($262.40 allowed amount x .20 = $52.48). This item/service falls within the prosthetic devices 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 waive the cost sharing for the ambulance services 
provided on April 20, 2023, the wrist fracture procedure provided on May 2, 2023, and the wrist x-ray, and the 
wrist brace provided on May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on March 03, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. 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 a home visit provided on 
March 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each office visit provided on January 27, 
2023, to March 23, 2023. 
 
You asked the Plan to waive the copayment for each office visit. 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 $50 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $50 copayment for each office visit. This item/service falls within the outpatient 
diagnostic tests and therapeutic 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. The total you owe is $250 ($50 copayment x 5 visits = $250). 
Therefore, we decided that the Plan does not have to waive the copayment for each office visit provided on 
January 27, 2023, to March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on May 02, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration due to 
medical necessity. 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 nursing facility care 
provided on May 02, 2023.