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

 
We decided that the Plan does not have to waive the copayment for a soft tissue head and neck ultrasound 
provided on June 12, 2023. 
 
You asked the Plan to waive the copayment for a soft tissue head and neck ultrasound. You say that you 
disagree with the 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 $150 
copayment for other in-network Medicare-covered radiological diagnostic services including ultrasounds. 
 
You have been asked to pay a $150 copayment for a soft tissue head and neck ultrasound. This item/service falls within the other in-network Medicare-covered radiological diagnostic services including ultrasounds 
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 $115.70. Therefore, we 
decided that the Plan does not have to waive the copayment for a soft tissue head and neck ultrasound provided 
on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330) provided on July 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 December 29, 2021. 
Therefore, we decided that the Plan does not have to pay for panoramic imaging (D0330) provided on July 25, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
December 09, 2022, to December 14, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you have not been 
charged 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $390 
copayment for in-network inpatient hospital care.  
You have been asked to pay a $390 copayment for the inpatient hospital stay. This item/service falls within the 
in-network 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 a total of $1,560 for the inpatient hospital stay 
($390 copayment x 4 days = $1,560). You have not been charged for the day you were discharged. Therefore, 
we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
December 09, 2022, to December 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blepharoptosis surgery. 
 
You asked the Plan to pre-approve an eye lid surgery. You say that you need this surgery. The Plan denied your 
request. The Plan says this surgery has been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an eye lid surgery have been met. 
Medical records were requested on multiple occasions. The medical records were never received. Therefore, 
we decided that the Plan does not have to pre-approve a blepharoptosis surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the soft tissue grafting provided on May 10, 
2023. 
 
You asked the Plan to waive the copayment for the soft tissue grafting. You say that this was not for cosmetic 
reasons. 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 $315 
copayment for in-network outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $315 copayment for the soft tissue grafting. This item/service falls within the in-
network outpatient surgery provided at 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 soft tissue grafting provided on May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abutment supported crown (D6059) and a prefabricated 
abutment (D6056) provided on March 23, 2023. 
 
You asked the Plan to pay for D6059 and D6056. You say that this dental work was medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 Plan covers D6059 and 
D6056 when prior authorization is obtained.  
 
We looked at the file and Medicare rules. Authorization was sent after the dental service was provided. Based 
on this information, we decided that the Plan's rules for coverage of D6059 and D6056 have not been met. Therefore, we decided that the Plan does not have to pay for an abutment supported crown (D6059) and a 
prefabricated abutment (D6056) provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office services provided on February 08, 2023. 
 
You asked the Plan to pay for office services. You say that you are requesting reconsideration for 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 office services provided 
on February 08, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from May 9, 2023, to June 7, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you verified with the provider's office that they 
accepted your insurance. The Plan denied your request. The Plan says a Marriage and Family Therapy provider 
is not a covered type of mental health care provider under your Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from May 9, 2023, to 
June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites for teeth #21 and #29 provided on 
April 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that your tooth cracked, and you needed it fixed. 
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 September 16, 2022 for tooth #29, and October 7, 2022 for tooth #21. Therefore, we decided that the Plan does not have to pay for 
resin-based composites for teeth #21 and #29 provided on April 18, 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. 
 
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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network cardiac rehab visits provided on 
June 01, 2023, to June 29, 2023. 
 
You asked the Plan to waive the copayment for in-network cardiac rehab visits. You say that you were told this 
was covered at 100% and now youre getting a bill. You feel you should not have to pay this. 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 
copayment for cardiac rehabilitation services. 
 
You have been asked to pay a $10 copayment for in-network cardiac rehab visits. This item/service falls within 
the cardiac rehabilitation 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 $90 ($10 copayment x 9 visits = $90). Therefore, we 
decided that the Plan does not have to waive the copayment for in-network cardiac rehab visits provided on 
June 01, 2023, to June 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an arthroplasty procedure, and a tendon 
transfer provided on June 09, 2023. 
 
You asked the Plan to reduce the coinsurance for an arthroplasty procedure, and a tendon transfer. You say that 
you were not told that the provider was out-of-network. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for each out-of-network ambulatory surgical center service. 
 
You have been asked to pay 40% coinsurance for an arthroplasty procedure, and a tendon transfer. This 
item/service falls within the each out-of-network ambulatory surgical center service 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 
$888.90 ($2222.26 allowed amount x 40% = $888.90). Therefore, we decided that the Plan does not have to 
reduce the coinsurance for an arthroplasty procedure, and a tendon transfer provided on June 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve an RFA. You say that the enrollee has severe pain, and the requested 
procedure would be beneficial. The Plan denied your request. The Plan says the requested procedure is 
considered experimental and has not been proven to be beneficial for the enrollee's condition. 
 
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 an RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested procedure is the subject of ongoing clinical trials and is considered experimental 
at this time. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a genicular nerve radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0367) provided on March 14, 
2023. 
 
You asked the Plan to pay for D0367. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the denied dental service is not a covered 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 pay for a cone 
beam CT capture (D0367) provided on March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on February 10, 2023. 
 
You asked the Plan to pay for physician services. You say that you are requesting reconsideration for 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 physician services 
provided on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on June 28, 
2023. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the enrollee does not meet 
criteria as the enrollee does not have a covered diagnosis for the requested services as per the EOC. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services provided on June 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided on 
November 05, 2021, to November 16, 2021. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that you were told this 
would be covered by the Covid relief fund. 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 inpatient hospital care.  
You have been asked to pay a $325 copayment for an in-network inpatient 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. At the time of your admission, you were no longer eligible for the relief fund. You have 
been asked to pay a total of $1950 for the inpatient hospital stay ($325 copayment x 6 days = $1950). You have 
not been charged for the day you were discharged. Therefore, we decided that the Plan does not have to waive 
the copayment for an in-network inpatient stay provided on November 05, 2021, to November 16, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection services provided on May 23, 
2023. 
 
You asked the Plan to waive the copayment for the injection services. You say that you disagree with the 
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 $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $325 copayment for the injection services. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 $293.60. Therefore, we decided that the Plan does not have to 
waive the copayment for the injection services provided on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99309 and G8427 billed for date of service 
April 28, 2023. 
 
You asked the Plan to pay for procedure codes 99309 and G8427. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT codes 99309 and G8427 are not supported. Specifically, codes 99309 and G8427 have been 
billed with modifier "HE," which designates a non-covered service. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99309 and G8427 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99309 and G8427 billed for date of service April 28, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 
provided on May 27, 2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine. You say that you 
are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says the vaccine is 
covered under your Part D (pharmacy) benefits, and not your medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria 
Toxoids and Acellular Pertussis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Tetanus, 
Diphtheria Toxoids and Acellular Pertussis vaccine. Therefore, we decided that the Plan does not have to pay 
for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine provided on May 27, 2023.  
 Benefits for Tetanus, Diphtheria Toxoids and Acellular Pertussis vaccine 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 pay for the office visit provided on May 16, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that this should be covered because the provider is in-
network. The Plan denied your request. The Plan says this is a non-covered service under your insurance plan. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on May 16, 2023, by an 
OON provider.