Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381), 
gingival irrigation (D4921), and drugs or medicaments dispensed in the office (D9630), provided on October 
18, 2022. 
 
You asked the Plan to pay for D4381, D4921, and D9630. You say that you would like to be fully reimbursed 
because your denture never fit correctly. 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 the localized delivery of antimicrobial agents (D4381), gingival irrigation (D4921), and drugs or medicaments 
dispensed in the office (D9630), provided on October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the pool club membership (A9270) 
purchased on October 22, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service not a covered benefit.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
  
 
The Plans rules for coverage of gym benefits have not been met because the membership purchased is not 
covered under the wellness allowance benefit. Specifically, the plan reimburses you up to $150 per calendar 
year towards your cost for membership in a qualified health club or fitness facility. A qualified health club or 
fitness facility provides cardiovascular and strength training exercise equipment on site and will include an 
orientation to the facility and the equipment for each member. This benefit does not include membership fees 
you pay for sports clubs or social clubs. Therefore, we decided that the Plan does not have to issue 
reimbursement for the pool club membership (A9270) purchased on October 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination provided on December 01, 2022. 
 
You asked the Plan to pay for radiologic examination. You say that you are requesting reconsideration for the 
services provided. 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 radiologic examination 
provided on December 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on December 01, 2022. 
 
You asked the Plan to pay for rest home visit. You say that you say that the assisted living facility was 
responsible for 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 rest home visit provided 
on December 01, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from 
October 23, 2022, to October 27, 2022. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you used an in-
network provider. 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 $298 
copayment per day, for days 1 to 7 and a $0 copayment per day, for days 8 to 90 for in-network inpatient 
services.  
 
 You have been asked to pay a $298 copayment per day, for days 1 to 4 of the inpatient hospital stay. You have 
been asked to pay a total of $1,192 ($298 copayment x 4 days = $1,192). You have not been asked to pay for 
any additional days. This item/service falls within the inpatient hospital care benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce the copayment for the inpatient hospital stay provided from October 23, 2022, to 
October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on March 
03, 2023. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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/outpatient hospital facility. 
 
You have been asked to pay a $325 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/outpatient hospital facility 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 outpatient surgery provided on March 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit on January 27, 2023. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that the services were approved and 
would like the claim to be reprocessed. 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% 
coinsurance for out-of-network provider and professional services at primary care providers office (PCPs) 
and specialists office. Covered services include medically necessary medical care or surgery services 
furnished in a physicians office, certified ambulatory surgical center, hospital outpatient department, or any 
other location. The provider billed in the amount of $1,225 and the allowed amount is $334.86. $334.86 x 40% 
= $133.94. Therefore, results in the total cost sharing amount of $133.94. 
 
You have been asked to pay a 40% coinsurance for an office visit. This item/service falls within the 
physician/practitioner services, including doctor's 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 coinsurance for an office visit on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a specialist visit provided on February 18, 
2022. 
 
You asked the Plan to waive the coinsurance for a specialist visit. You say that you did not receive services 
from this provider. 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 out-of-network Medicare-covered physician specialist services. 
 
You have been asked to pay 40% coinsurance for a specialist visit. This item/service falls within the out-of-
network Medicare-covered physician specialist 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 $60.80 ($152 allowed amount x 40% = 
$60.80). Therefore, we decided that the Plan does not have to waive the coinsurance for a specialist visit 
provided on February 18, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services and inpatient 
hospital care provided on December 12, 2022, to December 15, 2022. 
 
You asked the Plan to waive the copayment for emergency room services and inpatient hospital care. You say 
that you disagree with the copayments. 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 $90 
copayment for emergency care and a $250 copayment per day for days 1-6 for Inpatient hospital care.  
 You have been asked to pay a $90 copayment for emergency room services and a $250 copayment per day for 
days 1-6 for inpatient hospital care. The total amount you are being asked to pay for inpatient care is $750 
($250 x 3 days = $750). The total amount you are being asked to pay is $840 ($750 + $90 = $840). This 
item/service falls within the emergency care and Inpatient hospital care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for emergency room services and inpatient hospital care provided on 
December 12, 2022, to December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6740), a pontic (D6245), and a 
prefabricated post and core (D2950), provided on January 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that the bridge for these teeth was necessary. The 
Plan denied your request. The Plan says your benefit for your combined allowance for supplemental preventive 
and comprehensive dental services every 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 enrollees combined dental allowance was exhausted on date of service January 23, 2023. Therefore, 
we decided that the Plan does not have to pay for a retainer crown (D6740), a pontic (D6245), and a 
prefabricated post and core (D2950), provided on January 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network laboratory draw provided on 
February 24, 2023. 
 
You asked the Plan to waive the copayment for an in-network laboratory draw. You say that you thought this 
was part of your annual, and that it would not have a 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 $15 
copayment for laboratory tests (outpatient). 
 
You have been asked to pay a $15 copayment for an in-network laboratory draw. This item/service falls within 
the laboratory tests (outpatient) 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 laboratory draw provided on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 23, 
2023. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you have been seeing this 
provider for years. 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 $45 
copayment for in-network Medicare-covered podiatry visits. 
 
You have been asked to pay a $45 copayment for a specialist visit. This item/service falls within the in-network 
Medicare-covered podiatry 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 a 
specialist visit provided on January 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99306 provided on January 28, 2022. 
 
You asked the Plan to pay for procedure code 99306. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 24, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for procedure code 99306 have not been met.  
Therefore, we decided that the Plan does not have to pay for procedure code 99306 provided on January 28, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on December 21, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your wife 
called for the ambulance services after you fell and became unconscious. The ambulance crew performed an 
electrocardiogram and recommended you go to the hospital but you refused. The Plan denied your request. The 
Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 21, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment with no 
transport provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites (D2391) for tooth #20 and #21 
provided on February 7, 2023 
 
You asked the Plan to pay for the dental services. You say that you needed the services done due to medical 
reasons and you are appealing the denied dental procedures. 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 your benefit for the requested items or services was exhausted on the date of service of May 18, 2022. 
Therefore, we decided that the Plan does not have to pay for the resin-based composites (D2391) for tooth #20 
and #21 provided on February 7, 2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on January 24, 2023. 
 
You asked the Plan to pay for the dental service. You say that you pay the highest level for dental care and you 
do not understand why the claim was denied. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the comprehensive periodontal evaluation 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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided on January 17, 2023. 
 
You asked the Plan to pay for a core build-up. You say that you do not understand why this is not covered. The 
Plan denied your request. The Plan says the rendered 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 core 
build-up (D2950) provided on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral radiographic images (D0220 and D0230), 
the panoramic radiographic images (D0330), a pontic (D6245), and retainer crowns (D6740) for tooth #5 and 
#6 provided on December 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were entitled to the services, and you 
were told they would be covered. The Plan denied your request. The Plan says your annual dental benefit 
maximum 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 $1,000 for dental services on December 28, 2022; therefore, your annual dental benefit 
maximum for the year of 2022 was exhausted on the date of service of December 28, 2022. Therefore, we 
decided that the Plan does not have to pay more for the intraoral radiographic images (D0220 and D0230), the 
panoramic radiographic images (D0330), a pontic (D6245), and retainer crowns (D6740) for tooth #5 and #6 
provided on December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110) and the office visit (99203) 
provided from January 11, 2023, through January 26, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the therapeutic exercises (97110) and the office visit (99203) provided 
from January 11, 2023, through January 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery on January 09, 2023. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you shouldn't have to pay for 
the surgery. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per day for outpatient hospital services. The plan covers medically necessary services you get in the 
outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered services include 
but are not limited to services in an emergency department or outpatient clinic, such as observation services or 
outpatient surgery. The provier billed in the amount of $1,063 and the allowed amount is $281.69. This is less 
than the copayment amount. Therefore, results in the total cost sharing amount of $281.69. 
 You have been asked to pay a $281.69 copayment which is less than for outpatient surgery. 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 outpatient surgery on January 09, 2023.