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 vascular duplex scan 
provided on February 08, 2023. 
 
You asked the Plan to waive the copayment for an in-network vascular duplex scan. You say that this should be 
a screening test with no copayment due. 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 $40 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $40 copayment for an in-network vascular duplex 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 vascular duplex scan provided on February 08, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on March 13, 2023. 
 
You asked the Plan to waive the copayment for lab services. You say that these services should be covered 
with no member responsibility. 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 $40 
copayment for each in-network freestanding laboratory visit. 
 
You have been asked to pay a $40 copayment for lab services. This item/service falls within the each in-
network freestanding laboratory visit 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 $7.29. Therefore, we decided that the Plan does not have to waive the copayment for lab services 
provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on February 23, 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 February 23, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the inclisiran injection, and the 
administration provided by an in-network provider on March 1, 2023. 
 
You asked the Plan to reduce the cost sharing for the injection and the administration. You say that you were 
told that the cost sharing would be lower. 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 20% 
coinsurance for all other drugs covered under Medicare Part B. 
 
 You have been asked to pay a $681.03 coinsurance for the injection ($3405.16 allowed amount x .20 = 
$681.03. You have also been asked to pay a $3.34 coinsurance for the administration ($16.72 allowed amount x 
.20 =$3.34). These items/services fall 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 sharing for the inclisiran injection, and the administration provided by 
an in-network provider on March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified adjunctive procedures (D9999) provided on 
September 7, 2022. 
  You asked the Plan to pay for the dental services. You say that the provider told you that the Plan would pay 
for the dental services, and you called the Plan so they could reimburse you the chargers. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the unspecified adjunctive 
procedures 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 pay for the 
unspecified adjunctive procedures (D9999) provided on September 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide or lift.  
 
You asked the Plan to pre-approve a stair glide. You say that you would like reconsideration because the 
requested stair glide or lift is medically necessary. The Plan denied your request. The Plan says the requested 
stair glide or lift is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide or lift.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tetanus, Diphtheria, and Pertussis vaccine provided on 
March 16, 2023. 
 
You asked the Plan to pay for Tetanus, Diphtheria, and Pertussis vaccine. You say that it is medically 
necessary. The Plan denied your request. The Plan says this vaccine is not eligible under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, Diphtheria, 
and 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, and Pertussis vaccine. Therefore, we decided that the Plan does not have to pay for Tetanus, 
Diphtheria, and Pertussis vaccine provided on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140, D7210), therapeutic parenteral drugs, 
two or more administrations, different medications (D9612) and panoramic radiographic image (D0330) 
provided on August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for extractions and panoramic radiographic image has already been 
exhausted. Therapeutic parenteral drugs are 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, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service October 1, 2021. 
Therefore, we decided that the Plan does not have to pay for extractions (D7140, D7210), therapeutic 
parenteral drugs, two or more administrations, different medications (D9612) and panoramic radiographic 
image (D0330) provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220) provided on April 
11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were never told that the dental services 
would not be covered. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 the Plan paid for an intraoral radiographic image (D0220) on April 11, 2023; therefore, your benefit for 
the requested items or services was exhausted on the date of service of April 11, 2023. Therefore, we decided 
that the Plan does not have to pay for the intraoral radiographic images (D0220) provided on April 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the MRI scan provided on March 6, 2023, by an 
OON provider.  
 
You asked the Plan to reimburse you for the MRI scan. You say that you would like to be reimbursed for the 
MRI you received, because if you would have gone somewhere else you would not have been seen so quickly. 
The Plan denied your request. The Plan says the service can be provided by an in-network provider. 
 
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 reimburse you 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 reimburse you for these 
items/services. Therefore, we decided that the Plan does not have to reimburse you for the MRI scan provided 
on March 6, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you thought he was in network. 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 dental services provided on February 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown (D6751) for teeth 6, 9, and 11, and 
pontic - porcelain fused to predominantly base metal (D6241) for teeth 7, 8, and 10.  
 
You asked the Plan to pre-approve retainer crown (D6751) for teeth 6, 9, and 11, and pontic - porcelain fused 
to predominantly base metal (D6241) for teeth 7, 8, and 10. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the services are medically necessary. 
 
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 retainer 
crown (D6751), and pontic - porcelain fused to predominantly base metal (D6241) when the services are 
medically necessary and reasonable.  
 
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 retainer crown (D6751) for teeth 6, 9, 
and 11, and pontic - porcelain fused to predominantly base metal (D6241) for teeth 7, 8, and 10. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is not any active disease process notes on the x-rays or the photograph. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crown (D6751) for teeth 6, 9, and 11, and pontic - porcelain fused to 
predominantly base metal (D6241) for teeth 7, 8, and 10 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crown (D6751) for teeth 6, 9, and 11, and pontic - porcelain fused to 
predominantly base metal (D6241) for teeth 7, 8, and 10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more and to cover the dental services as a medical procedure for 
a periodic oral evaluation (D0120), a cleaning (D1110), a custom implant abutment (D6057) for tooth #13, 
orthodontic retention (D8680), the treatment plan and records (D8999) provided on February 28, 2023, April 
17, 2023, and April 25, 2023. 
 You asked the Plan to pay more and to cover the dental services as a medical procedure for the dental services. 
You say that you are requesting the Plan to cover the procedure as a medical procedure. The Plan denied your 
request. The Plan says your annual dental maximum benefit for the year 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 the Plan paid $64 for dental services on February 13, 2023. On February 28, 2023, the Plan paid $1,436 
for dental services. For the year of 2023 the Plan paid $1,500 ($64 paid + $1,436 paid) for dental services; 
therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of 
February 28, 2023. Therefore, we decided that the Plan does not have to pay more and to cover the dental 
services as a medical procedure for a periodic oral evaluation (D0120), a cleaning (D1110), a custom implant 
abutment (D6057) for tooth #13, orthodontic retention (D8680), the treatment plan and records (D8999) 
provided on February 28, 2023, April 17, 2023, and April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation - established patient 
(D0120), and prophylaxis - adult (D1110) provided on March 30, 2023. 
 
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis - adult . You say that the plan 
paperwork says in black and white the dental insurance covers up to $1,500 for any licensed dentist and they 
did but it wasn't fully 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.  
 
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 a periodic oral evaluation - established 
patient (D0120), and prophylaxis - adult (D1110) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on January 5, 2023, to January 23, 2023. 
 
You asked the Plan to pay for local anesthesia in conjunction with operative or surgical procedures . You say 
that this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on January 5, 2023, to 
January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on April 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that your provider mistakenly told you that they 
accepted your dental insurance. 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 the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retreatment of previous root canal therapy - molar (D3348) 
provided on January 5, 2023. 
 
You asked the Plan to pay for retreatment of previous root canal therapy - molar. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
retreatment of previous root canal therapy - molar (D3348) provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a periodic oral evaluation - established 
patient (D0120), prophylaxis - adult (D1110), and bitewings - three radiographic images (D0273) provided on 
February 6, 2023. 
 
You asked the Plan to waive the coinsurance for the dental services represented by codes D0120, D1110 and 
D0273. 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 all out-of-network non-Medicare covered preventive and comprehensive dental services.  
  
 You have been asked to pay 20% coinsurance for the dental services represented by codes D0120, D1110 and 
D0273. These services fall within the dental 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 
coinsurance for a periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), and 
bitewings - three radiographic images (D0273) provided on February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a medical eye examination and fundus 
photography provided on August 1, 2022. We also decided that the Plan does not have to waive the copayment 
for a determination of refractive state provided on August 1, 2022.  
 
You asked the Plan to waive the deductible for a medical eye examination and fundus photography. You also 
asked the Plan to waive the copayment for a determination of refractive state. You say that this should have 
been classified as an out-of-network specialty visit. You also say your share should only be $65. 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 $1000 deductible which applies to certain items and services. The 
Plan deductible applies to a medical eye examination, a determination of refractive state, and fundus 
photography. The Plan contract also says there is a $65 copayment for each out-of-network Medicare-covered 
examination. 
 
You have been asked to pay $179.76 toward the deductible for these services. You have also been asked to pay 
$21.10, which is less than the $65 out-of-network copayment for a determination of refractive state. The 
services you asked the Plan to waive the deductible for falls within the vision services benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which 
applies to a medical eye examination and fundus photography. The Plan has also followed Medicare rules by 
clearly disclosing in the contract that there is a $65 copayment for a determination of refractive state. This cost 
sharing is a contractual obligation that had not been met at the time a medical eye examination, a determination 
of refractive state and fundus photography was received on August 1, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for a medical eye examination and fundus photography provided on 
August 1, 2022. We also decided that the Plan does not have to waive the copayment for a determination of 
refractive state provided on August 1, 2022.