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

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on April 18, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were not aware that you would 
have a 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 $85 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $85 copayment for an ultrasound. This item/service falls within the in-network 
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 ultrasound provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 22, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for psychotherapy. You say that you are requesting reconsideration for the service 
provided. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 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 psychotherapy provided on May 22, 2023, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of an erupted tooth requiring removal 
of bone and/or sectioning of tooth (D7210 x2), other drugs and/or medicaments (D9630 x2), and bone 
replacement graft - first site in quadrant (D4263 x2). 
 
You asked the Plan to pre-approve surgical removal of an erupted tooth, drugs, and bone replacement graft. 
You say that the services are necessary. The Plan denied your request. The Plan says the requested services are 
not covered. 
 
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 surgical removal of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x2), other 
drugs and/or medicaments (D9630 x2), and bone replacement graft - first site in quadrant (D4263 x2).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the aspiration of cyst of breast, and the 
ultrasonic guidance for needle placement provided by an out-of-network provider on March 20, 2023. 
 
You asked the Plan to waive the copayment for the aspiration of cyst, and the ultrasonic guidance. You say that 
you think that the provider is in-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 a $20 
copayment for in and out-of-network services from a specialist or under certain circumstances, treatment by a 
nurse practitioner, physicians assistant, or other non-physician health care professional in a specialists office, 
and a $140 copayment for in and out-of-network Medicare-covered radiological diagnostic services, including 
ultrasounds, performed in a physicians office or at a free-standing facility (such as a radiology center or 
medical clinic). 
 
You have been asked to pay a $20 copayment for the aspiration of cyst. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. You have also been asked to 
pay a $58.48 copayment for the ultrasonic guidance because the allowed amount for this service is less than the 
$140 copayment. 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 the aspiration of cyst of 
breast, and the ultrasonic guidance for needle placement provided by an out-of-network provider on March 20, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 14, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says enrollees must receive their care from a 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 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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 14, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
provided on July 12, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014). You say that you want the 
claim properly coded so that you do not have to have financial 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 $35 
copayment for Medicare-covered eye examinations to diagnose and treat diseases and conditions of the eyes. 
 
You have been asked to pay a $35 copayment for a medical eye examination (92014). This item/service falls within the Medicare-covered eye examinations to diagnose and treat diseases and conditions of the eyes 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 medical eye examination (92014) provided on 
July 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network non emergent ambulance 
ride to and from treatment provided on March 24, 2023. 
 
You asked the Plan to waive the copayment for an out-of-network non emergent ambulance ride to and from 
treatment. You say that the patient needed this service to get to and from treatments.. 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 ambulance services. 
 
You have been asked to pay a $300 copayment for an out-of-network non emergent ambulance ride to and 
from treatment. This item/service falls within the 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. However, since the allowed amount is 
less than the standard copayment, you only owe $219.48. You only pay one copayment per date of service. 
Therefore, we decided that the Plan does not have to waive the copayment for an out-of-network non emergent 
ambulance ride to and from treatment provided on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 07, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on June 07, 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 May 13, 2023. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
were given medications to take at home, you thought this would be covered and paid for. 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 $120 
copayment for emergency services. 
 
You have been asked to pay a $120 copayment for an in-network emergency room (ER) visit. This item/service 
falls within the emergency 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 emergency room (ER) visit provided on May 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network podiatry visit provided on 
April 18, 2023. 
 
You asked the Plan to waive the copayment for an in-network podiatry visit. You say that the provider cut your 
nails and poked your foot with a needle. There was no true exam done and you feel you should not have to pay 
a copayment for 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 $40 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for an in-network podiatry visit. This item/service falls within 
the Physician/Practitioner services, including doctors office visits 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 podiatry visit provided on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation - established patient 
(D0120), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided on May 8, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that the office told you that you would only 
owe $86.00. You also say that then you were charged $49.00 after being told your plan had out-of-network 
benefits that should cover it. 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 the periodic oral evaluation - established 
patient (D0120), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided on 
May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment and collection and application 
of autologous blood concentrate product (D6057, D7921) provided on February 12, 2023, to February 13, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 custom 
fabricated abutment and collection and application of autologous blood concentrate product (D6057, D7921) 
provided on February 12, 2023, to February 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 13, 2023. 
 
You asked the Plan to pay for an office visit. You say that you say that submitted a request for prior 
authorization form. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a root canal (D3330) provided on June 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 a root canal (D3330) provided on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation and therapeutic parenteral drugs (D9310, 
D9612) provided on May 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
consultation and therapeutic parenteral drugs (D9310, D9612) provided on May 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint (SIJ) denervation (64625). 
 
You asked the Plan to pre-approve SIJ denervation. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ Denervation (also called Radiofrequency 
Ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SIJ denervation have not been met. Therefore, we decided that the Plan does not have to pre-
approve sacroiliac joint (SIJ) denervation (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and an intraoral - 
periapical first radiographic image (D0220) provided on June 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have a dental condition. You also say the 
filling needs to be replaced or repaired. The Plan denied your request. The Plan says your benefit for a periodic 
oral evaluation (D0120) has already been exhausted. The Plan also says that for an intraoral - periapical first 
radiographic image (D0220), 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.  
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for a periodic oral evaluation (D0120) was exhausted on date of service April 27, 2023. 
You have also been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for an intraoral - periapical first radiographic image (D0220). 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 for a periodic oral evaluation (D0120) and an intraoral - periapical first radiographic image (D0220) 
provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network skilled nursing facility 
visit provided on January 31, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network skilled nursing facility visit. You say that 
you do not agree with this coinsurance amount. 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 Provider and Professional Services. 
 
You have been asked to pay 40% coinsurance for an out-of-network skilled nursing facility visit. This 
item/service falls within the Provider and Professional 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 $75.33 ($188.33 allowed 
amount x 40% = $75.33) Therefore, we decided that the Plan does not have to waive the coinsurance for an 
out-of-network skilled nursing facility visit provided on January 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an oxygen concentrator and a portable 
oxygen system provided on June 28, 2023. 
 
You asked the Plan to reduce the coinsurance for an oxygen concentrator and a portable oxygen system. You 
say that you usually pay less for these items. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for an oxygen concentrator and a portable oxygen system. This 
item/service falls within the durable medical equipment 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 reduce the coinsurance for an oxygen concentrator and a portable oxygen system provided on 
June 28, 2023.