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

 
We decided that the Plan does not have to pay for the Whey protein, the Tums Berries vitamins (x2) and the 
Opti-free replenishing solution from January 15, 2023, to March 12, 2023. 
 
You asked the Plan to pay for the over-the-counter items. You say that you were told to make purchases and 
submit claims afterwards. You say there was no information available at the time from the Plan to choose 
covered purchases. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover OTC services. However, the Plan offers an OTC benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested items are not among 
those covered under this benefit. Specifically, the items were purchased at retail stores. Therefore, we decided that the Plan does not have to pay for the Whey protein, the Tums Berries vitamins (x2) and the Opti-free 
replenishing solution from January 15, 2023, to March 12, 2023.  
 
Your complaint about the Plans poor customer service is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 5, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that this is supported in the records. 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 items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on April 5, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the new patient office visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that you do not trust the in-network providers. The 
Plan denied your request. The Plan says you must receive your 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
new patient office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 16, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office vist. 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 an office visit provided on February 16, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for each office visit provided on March 29, 2023, to April 13, 
2023. 
 
You asked the Plan to pay for each office visit. You say that you were focused on your recovery, and did not 
know the providers were out-of-network. 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 each office visit 
provided on March 29, 2023, to April 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for in-network wound care supplies provided 
from November 16, 2022, to February 2, 2023. 
 
You asked the Plan to waive the coinsurance for in-network wound care supplies. You say that you should not 
have to pay so much for bandages. You never had to before, and you shouldn't have to now. 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 durable medical equipment (DME) and related supplies.  
 The allowed amount of these items is $374.80, resulting in a coinsurance amount of $74.96 ($374.80 x 20% = 
$74.96). 
 
You have been asked to pay a $74.96 coinsurance for in-network wound care supplies. This item/service falls 
within the durable medical equipment (DME) 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 waive the coinsurance for in-network wound care supplies provided from November 16, 2022, to February 2, 
2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient physical therapy visits to be provided by 
an OON provider.  
 
You asked the Plan to pre-approve outpatient physical therapy visits. You say that the out-off-network provider 
is closer for you than the in-network providers. 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the outpatient physical therapy visits to be provided 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 21, 2023. 
 
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 $1,500 annual maximum has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pay for dental services provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 provided 
on February 8, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96521, and J1817. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered.  
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin therapy. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and 
J1817 provided on February 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on June 6, 2022, and July 14, 2022. 
 
You asked the Plan to pay for the foot orthotics. You say that you are appealing the claim that has been denied 
and have provided additional records for review. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on June 6, 2022, 
and July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Colgate toothpaste, the Colgate toothbrushes, and 
Refresh Lubricated Eyedrops provided from January 4, 2023, to February 19, 2023. 
 
You asked the Plan to pay for the over-the-counter (OTC) items. You say that you were told to make purchases 
and submit claims afterwards. You say there was no information available at the time from the Plan to choose 
covered purchases. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover OTC services. However, the Plan offers an OTC benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Specifically, the items were purchased at retail stores which are not an 
eligible provider. Therefore, we decided that the Plan does not have to pay for the Colgate toothpaste, the 
Colgate toothbrushes, and Refresh Lubricated Eyedrops provided from January 4, 2023, to February 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable chest x-rays provided on April 13, 2023, and 
May 01, 2023, by an OON provider.  
 
You asked the Plan to pay for the portable x-rays. You say that you are appealing the denials with supporting 
documentation. The Plan denied your request. The Plan says these services were not authorized. 
 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the portable chest x-rays provided on April 13, 
2023, and May 01, 2023, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 6, 2023, to January 19, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you believe the 
enrollee is being incorrectly charged for this stay. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $260 copayment per day for days 1-4 of each in-network inpatient hospital stay. The enrollees 
contract with the Plan also clearly says that enrollees then pay a $0 copayment per day for any additional days 
of the same in-network inpatient hospital stay. 
 
The Plan contract says that the inpatient hospital care copayment applies to each admission, including when the 
enrollee is transferred. The enrollee has been asked to pay a $260 copayment per day for days 1-4 of the 
inpatient hospital stay. This item/service falls within the inpatient hospital care benefit category. The enrollee 
has not been asked to pay after day four or for the day they were discharged. The enrollee has been asked to 
pay a total of $1,040 for the inpatient hospital stay ($260 copayment per day x 4 days = $1,040). This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided from January 6, 2023, to 
January 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs on May 16, 2023.  
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you should not have to owe for 
injection that you never received. 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 Medicare Part B prescription drugs. The provider billed in the amount of $9,100 and the 
allowed amount is $534.71 for the service. $534.71 x 20% = $106.94. The provider billed in the amount of 
$16,380 and the allowed amount is $962.48 for the service. $962.48 x 20% = $192.50. The provider also billed 
in the amount of $1,829 and the allowed amount is $106.94 for the service. $106.94 x 20% = $21.39. For all 
services it's, $106.94 + $192.50 + $21.39 = $320.83. Therefore, results in the total cost shairng amount of 
$320.83. 
 
You have been asked to pay a 20% coinsurance for Part B drugs. This item/service falls 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 waive the coinsurance for Part B 
drugs on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete lower denture (D5120) provided on  
May 18, 2023. 
 
You asked the Plan to pay more for this dental item. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 complete lower denture (D5120) 
provided on May 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 18, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
walked to your local fire department where the responder took your vitals and did an EKG on site with no 
abnormalities. You also say you were advised to eat something and you would feel better so there was no 
transportation. 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 May 18, 2023. 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 the ambulance response and treatment with no 
transport provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an abutment supported porcelain/ceramic crown and 
fillings for teeth numbers 6, 7, 8, 9, 10, 11, 22, 23, 24, and 25 (D2335, D6058) provided on April 28, 2023, to 
May 11, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 28, 2023, and May 
11, 2023. Therefore, we decided that the Plan does not have to pay more for an abutment supported 
porcelain/ceramic crown and fillings for teeth numbers 6, 7, 8, 9, 10, 11, 22, 23, 24, and 25 (D2335, D6058) 
provided on April 28, 2023, to May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral splint (D4323) provided on April 14, 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 an oral 
splint (D4323) provided on April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 25, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the provider is in-network. 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 office visit provided on April 25, 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 a cone beam CT capture (D0365). 
 
You asked the Plan to pre-approve D0365. You say that you have a hyper-sensitive tooth and need this dental 
work done. The Plan denied your request. The Plan says the requested 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 pre-approve a 
cone beam CT capture (D0365).