Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an injection, a diagnostic radiology service, 
and a specialist visit provided on December 1, 2022. 
 
You asked the Plan to waive the cost share for an injection, a diagnostic radiology service, and a specialist 
visit. You say that you disagree with the copayment applied and feel you were overcharged. 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 Medicare Part B covered chemotherapy and non-chemotherapy drugs, 20% coinsurance for 
diagnostic radiology services, not including x-rays, and a $35 copayment for each Medicare-covered specialist 
visit.  
 
You have been asked to pay $49.06 for an injection, a diagnostic radiology service and a specialist visit. This 
total includes $12.32 coinsurance, which is 20% of the allowed amount for an echo guide for an injection or 
biopsy ($61.58 allowed x 20% = $12.32), $1.74 coinsurance, which is 20% of the allowed amount for 
Medicare Part B drug injection, ($8.74 allowed x 20% = $1.74), and a $35 copayment for a specialists visit. 
The injection falls within the Medicare Part B prescription drugs benefit category. The echo guide diagnostic 
imaging falls within the outpatient diagnostic tests benefit category. The specialist visit falls within the 
physician/practitioner services. 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 cost share for an injection, a diagnostic 
radiology service, and a specialist visit provided on December 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 18, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you feel that you are not 
liable. 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 $295 
copayment for in and out-of-network one-way ground trip ambulance services. 
 
You have been asked to pay a $295 copayment for ambulance services. This item/service falls within the in and 
out-of-network one-way ground trip 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. Therefore, we decided that the Plan does not have to waive 
the copayment for ambulance services provided on March 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trigger point triamcinolone injection with ultrasonic 
guidance provided on January 3, 2023, by an OON provider.  
 
You asked the Plan to pay for the trigger point triamcinolone injection with ultrasonic guidance. You say that 
the service was medically necessary. The Plan denied your request. The Plan says the service was 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 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 the trigger point triamcinolone injection with 
ultrasonic guidance provided on January 3, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by an out-of-network chiropractor 
(99213), x-rays (72100), mechanical traction (97012) and electrical stimulation (97014) provided from May 1, 
2023, to May 3, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that the provider is in-network and treatment 
cannot be given without x-rays. The Plan denied your request. The Plan says these chiropractic services are 
excluded from coverage and the provider is out-of-network. 
 
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 service at issue is not manual manipulation of the spine, and the provider is out-of-
network with the Plan. Therefore, we decided that the Plan does not have to pay for the office visit provided by 
an out-of-network chiropractor (99213), x-rays (72100), mechanical traction (97012) and electrical stimulation 
(97014) provided from May 1, 2023, to May 3, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for out-of-network outpatient mental health services 
provided from February 23, 2022, to December 20, 2022. 
 
You asked the Plan to waive the cost for in-network outpatient mental health services. You say that you were 
unaware that the provider was going in and out of network and being charged large amounts. 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 outpatient mental health care.  
 
The item or service you asked the Plan to waive the cost for falls within the outpatient mental health care 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1000 deductible which applies to outpatient mental health care. You have been asked to pay $269.82 towards 
that $1000 deductible. This cost sharing is a contractual obligation that had not been met at the time in-network 
outpatient mental health services was received on February 23, 2022, to December 20, 2022.  Therefore, we decided that the Plan does not have to waive the cost for out-of-network outpatient mental health 
services provided from February 23, 2022, to December 20, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management provided on March 10, 
2023. 
 You asked the Plan to pay for the hospital discharge day management. You say that the services were 
medically necessary. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management provided on March 10, 
2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 18, 2022. 
 You asked the Plan to pay for the office visit. You say that the enrollee was no longer on hospice when the 
services were rendered. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) and comprehensive 
oral evaluation (D0150) provided on March 20, 2023. 
 
You asked the Plan to pay for panoramic radiographic image and comprehensive oral evaluation. 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 
panoramic radiographic image (D0330) and comprehensive oral evaluation (D0150) provided on March 20, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental service. You say that you lost your denture, and you are in pain. 
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 the Plan paid for a complete upper denture (D5110) on February 18, 2021; therefore, your benefit for the 
requested item or service was exhausted on the date of service of February 18, 2021. Therefore, we decided 
that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330) provided on April 11, 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 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 11, 2023. 
Therefore, we decided that the Plan does not have to pay for endodontic therapy (D3330) provided on April 11, 
2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on December 20, 2022. 
 You asked the Plan to pay for the home visit. You say that the enrollee was not on hospice on this date. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a home visit provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
(D0230) provided on April 6, 2023. 
 
You asked the Plan to pay for the intraoral - periapical each additional radiographic image (D0230) provided 
on April 6, 2023 The Plan denied your request. The Plan says your benefit for the intraoral - periapical each 
additional radiographic image 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 service was exhausted on date of service April 6, 2023. You 
received the allowed frequency of one intraoral - periapical first radiographic image (D0220) on the appealed 
claim. Therefore, we decided that the Plan does not have to pay for an intraoral - periapical each additional 
radiographic image (D0230) provided on April 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept provided on April 16, 2023. 
 
You asked the Plan to pay for the paramedic intercept. You say that you were transported to the hospital on this 
date already have an ambulance charge. You also say that the provider is stating that this charge is separate and 
for the paramedics and not the trip itself. The Plan denied your request. The Plan says this paramedic intercept did not transport you to the nearest 
emergency department. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept provided on April 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an injection and a SPECT scan provided on 
May 1, 2023. 
 
You asked the Plan to reduce the cost share for an injection and a SPECT scan. You say that you do not 
understand why you are being charged more than the usual $150 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 20% 
coinsurance for Medicare Part B prescription drugs and a $150 copayment for each Medicare-covered 
diagnostic imaging.  
 
You have been asked to pay $198.92 for an injection and a SPECT scan. This total includes $48.92 
coinsurance, which is 20% of the allowed amount for an injection ($244.60 allowed x 20% = $48.92) and a 
$150 copayment for a SPECT scan. The injection falls within the Medicare Part B prescription drug benefit 
category. The SPECT scan falls within the outpatient diagnostic tests 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 share for an injection and a SPECT scan provided on May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and the intraoral 
complete series of radiographic images (D0210) provided by an out-of-network provider on March 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you could not find a participating provider and 
you were in pain, so you had to go to an out-of-network provider. 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 comprehensive oral evaluation (D0150) and the intraoral complete series of radiographic images 
(D0210) provided by an out-of-network provider on March 31, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on January 18, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the medical records 
support a medical necessity for ambulance transport. The Plan denied your request. The Plan says a physician's 
office is not a covered destination. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport, and ground mileage provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation - per site 
(D7953) provided on April 26, 2023. 
 
You asked the Plan to pay for bone replacement graft. 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 bone 
replacement graft for ridge preservation - per site (D7953) provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remove broken implant retaining screw (D6096), and 
replacement of restorative material used to close an access opening of a screw-retained implant supported 
prosthesis (D6197) provided on May 1, 2023, and May 4, 2023. 
 
You asked the Plan to pay for these dental services. 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 remove broken implant retaining screw (D6096), and replacement of restorative material used to close an access 
opening of a screw-retained implant supported prosthesis (D6197) provided on May 1, 2023, and May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the infiltration of sustained release therapeutic drugs 
(D9613). 
 
You asked the Plan to pre-approve the dental services. You say that you need the pain relief due to the oral 
surgery. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the infiltration of sustained release therapeutic drugs 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
infiltration of sustained release therapeutic drugs (D9613).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from May 3, 2023, to May 
4, 2023. 
 
You asked the Plan to pay for the medication. You say that you received the medications while you were in the 
hospital. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from May 3, 2023, to May 4, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous moderate (conscious) sedation/analgesia- first 15 
minutes (D9239) provided on April 13, 2023. 
 
You asked the Plan to pay for the intravenous moderate (conscious) sedation/analgesia. You say that you had to 
be put to sleep due to the time and pain of the surgery. You also say that your insurance will not cover for 
intravenous sedation but the medical would cover it. The Plan denied your request. The Plan says your plan 
does not cover this expense. 
 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 
intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) provided on April 13, 2023.