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

 
We decided that the Plan does not have to waive the copayment for an in-network abdomen computed 
tomography (CT) scan provided on July 25, 2022. 
 
You asked the Plan to waive the copayment for an in-network abdomen computed tomography (CT) scan. You 
say that you keep getting charged for these copayments, then they are refunded to you. 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 $300 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $300 copayment for an in-network abdomen computed tomography (CT) scan. 
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. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network abdomen computed tomography 
(CT) scan provided on July 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network biopsy procedure provided 
on February 01, 2023. 
 
You asked the Plan to waive the copayment for an in-network biopsy procedure. You say that you were not 
advised of this copayment. You are on a fixed income and cannot afford 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 $450 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $450 copayment for an in-network biopsy procedure. This item/service falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 biopsy 
procedure provided on February 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99213) and a determination of 
refractive state (92015) provided on November 16, 2022. 
 
You asked the Plan to pay for a specialist office visit (99213) and a determination of refractive state (92015). 
You say that no prior authorization was required because this is an ongoing requirement due to the glaucoma 
diagnosis. 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 specialist office visit 
(99213) and a determination of refractive state (92015) provided on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the principal care management services provided on July 06, 
2023. 
 
You asked the Plan to pay for the principal care management 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 principal care 
management services provided on July 06, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 26, 2021. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services 
provided on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an out-of-network provider 
on June 29, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you have been going to this dentist since 
2005. 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 dental services provided by an out-of-
network provider on June 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network hip procedure provided on 
June 07, 2023. 
 
You asked the Plan to waive the copayment for an in-network hip procedure. You say that this was a second 
procedure. Your first hip went septic after three weeks, which is why you had this done. You should not have 
to pay this copay. 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 hospital services. 
 
You have been asked to pay a $325 copayment for an in-network hip procedure. This item/service falls within 
the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an in-network hip procedure provided on June 07, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on November 24, 2022, to 
December 01, 2022. 
 
You asked the Plan to pay for skilled nursing facility. You say that you are requesting the reconsideration of 
the claim for payment and seeking for review. 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 skilled nursing facility 
provided on November 24, 2022, to December 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on February 21, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration asking for the review 
of the 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 lab testing provided on 
February 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammography provided on July 24, 
2023. 
 
You asked the Plan to waive the copayment for a mammography. You say that you believe the claim was 
coded wrong. 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 $25 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $25 copayment for a mammography. 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. Therefore, we decided that the Plan does not have to waive the 
copayment for a mammography provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110), and an immediate 
mandibular partial denture (D5222) provided on June 2, 2023. 
 
You asked the Plan to pay for D5110 and D5222. You say that you believe the Plan should pay for more. The 
Plan denied your request. The Plan says the denied dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
complete maxillary denture (D5110), and an immediate mandibular partial denture (D5222) provided on June 
2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chronic meals (S9977). 
 
You asked the Plan to pre-approve chronic meals (S9977). You say that you approve the meals for the member. 
The Plan denied your request. The Plan says the member was discharged on August 31, 2023. The Plan also 
says that the prior authorization request was received on September 28, 2023, which is more than 10 days 
following the member's discharge date. 
 
The Plan must follow Medicare rules. Medicare rules say that the rules state that meals may be offered as a 
supplemental benefit. The Plan rules say that they cover a $0 copayment for up to 2 meals a day for 10 days 
following the member's discharge date.  
We looked at the file and Medicare rules. The Plan rules say that they cover a $0 copayment for up to 2 meals a 
day for 10 days following the member's discharge date. The record shows the prior authorization request was 
received after the 10 days. Based on this information, we decided that Medicare rules for coverage of chronic 
meals (S9977) have not been met. Therefore, we decided that the Plan does not have to pre-approve chronic 
meals (S9977).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on May 23, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that it is the responsibility of the facility to 
obtain the prior 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 skilled nursing facility 
provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive periodontal evaluation (D0180), the 
intraoral radiographic images (D0220), bitewings (D0274), the panoramic radiographic image (D0330), and to 
pay for a comprehensive oral evaluation (D0150), the intraoral radiographic image (D0230), and the 
periodontal scaling and root planing (D4341) provided by an out-of-network provider on September 13, 2022, 
September 14, 2022, September 15, 2022, and October 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told that the procedures would 
be covered. 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. Your benefit 
limit for the comprehensive oral evaluation and the intraoral radiographic image has already been exhausted. 
Also, the periodontal scaling and root planing is 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, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation (D0150) was exhausted on the date of service of 
October 20, 2022. The record also shows that your benefit for the intraoral radiographic image (D0230) was 
exhausted on the date of service of September 13, 2022. You have been asked to pay the difference between the 
out-of-network providers charges and the Plans payment for comprehensive periodontal evaluation (D0180), 
the intraoral radiographic images (D0220), bitewings (D0274), the panoramic radiographic image (D0330). 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The periodontal 
scaling and root planing is not covered under the Plans dental benefit. Therefore, we decided that the Plan 
does not have to pay more for a comprehensive periodontal evaluation (D0180), the intraoral radiographic 
images (D0220), bitewings (D0274), the panoramic radiographic image (D0330), and to pay for a 
comprehensive oral evaluation (D0150), the intraoral radiographic image (D0230), and the periodontal scaling 
and root planing (D4341) provided by an out-of-network provider on September 13, 2022, September 14, 2022, 
September 15, 2022, and October 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retinal screening photography (S9986) provided on June 8, 
2023. 
 
You asked the Plan to pay for retinal screening photography (S9986). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says your benefit Plan does not cover this service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover these services. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one routine eye examination per 
year. Retinal screening photography is excluded from this benefit. Based on this information, we decided that 
the Plan's rules for coverage of retinal screening photography (S9986) have not been met. Therefore, we 
decided that the Plan does not have to pay for retinal screening photography (S9986) provided on June 8, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on January 04, 2023, to 
February 08, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you are requesting reconsideration of the 
claim denied as service not authorized denied due to no prior 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 skilled nursing facility 
provided on January 04, 2023, to February 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784), progressive lenses (V2781) 
miscellaneous vision items or services (V2799), anti-reflective coating (V2750), variable sphericity lenses 
(V2499) and ultra-violet lenses (V2755) provided on July 20, 2023. 
 
You asked the Plan to pay for polycarbonate lenses (V2784), progressive lenses (V2781) miscellaneous vision 
items or services (V2799), anti-reflective coating (V2750), variable sphericity lenses (V2499) and ultra-violet 
lenses (V2755). You say that you went to a provider to get some new glasses. You also say the provider sent 
you to get an eye examination, and you did not know they were authorized. The Plan denied your request. The 
Plan says this benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when . 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $300 benefit toward the purchase and 
fitting of eyeglasses and pair of lenses. The Plan rules also say that you pay any amount over the $300 retail 
price. The record shows this benefit has been exhausted with this date of service. Based on this information, we 
decided that the Plan's rules for coverage of polycarbonate lenses (V2784), progressive lenses (V2781) 
miscellaneous vision items or services (V2799), anti-reflective coating (V2750), variable sphericity lenses 
(V2499) and ultra-violet lenses (V2755) have not been met. Therefore, we decided that the Plan does not have 
to pay for polycarbonate lenses (V2784), progressive lenses (V2781) miscellaneous vision items or services 
(V2799), anti-reflective coating (V2750), variable sphericity lenses (V2499) and ultra-violet lenses (V2755) 
provided on July 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthodontic retention (D8680), an extraction of an erupted 
tooth or exposed root (D7140), a panoramic x-ray (D0330), an intraoral periapical each additional x-ray 
(D230), an intraoral periapical first x-ray (D0220), bitewings (D0274) and a comprehensive oral evaluation 
(D0150) provided on June 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you spoke with a Plan representative who stated 
that you were in-network with the Plan. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits.   
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for orthodontic retention (D8680), an extraction of an erupted tooth or exposed root (D7140), a 
panoramic x-ray (D0330), an intraoral periapical each additional x-ray (D230), an intraoral periapical first x-
ray (D0220), bitewings (D0274) and a comprehensive oral evaluation (D0150) provided on June 12, 2023.