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

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
limited oral evaluation - problem focused (D0140), resin-based composite - two surfaces, anterior (D2331), 
resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335), and resin-based 
composite - one surface, anterior (D2330) provided on November 2, 2022, to November 17, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D0220, D0140, D02331, D2335, and 
D2330. You say that you were not aware the previous dentist had left the practice. The Plan denied your 
request. The Plan says your benefit for the requested item or service $1,000 dollar limit was met.  
 Since your annual maximum has been satisfied by these claims no additional payment will be made towards 
resin-based composite  two surfaces anterior (D2331), resin-based composite  4 or more surfaces (D2335) or 
resin-based composite  one surface anterior (D2330). 
 
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 services was exhausted on date of service November 15, 2022. The Plan 
reprocessed the claims at the in-network level because you were not aware your previous dentist and left the 
dental practice and you had to use an out-of-network provider. 
 
Date of Service Total Charges Plan Paid Member Responsibility 
2/22/2022 $67.00 $47.00 $0.00 
4/4/2022 $243.00 $144.00 $0.00 
4/5/2022 $234.00 $186.00 $0.00 
11/2/2022 $140.00 $140.00 $0.00 
11/15/2022 $689.00 $483.00 $206.00 
TOTALS $1,373.00 $1,000 $206.00 
 
Therefore, we decided that the Plan does not have to pay for an intraoral - periapical first radiographic image 
(D0220), limited oral evaluation - problem focused (D0140), resin-based composite - two surfaces, anterior 
(D2331), resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335), and 
resin-based composite - one surface, anterior (D2330) provided on November 2, 2022, to November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
cardiologist. 
 
You asked the Plan to pre-approve a continuation of care with an OON cardiologist. You say that it is in the 
best interest of your mental, emotional, and physical health to continue treatment with the requested OON 
provider. You say that this OON provider has been your cardiologist since you were released from the hospital 
after having a heart attack. The Plan denied your request. The Plan says the care needed can be provided in-
network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a continuation of care with an OON 
cardiologist. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found that there are credentialed, experienced physicians within your network who could be utilized 
for your clinical condition. There is insufficient documentation to support the medical necessity for referral to 
an OON provider. Your medical management and/or follow-up care can be safely transitioned to an in-network 
specialist at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continuation of care with an OON cardiologist have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
cardiologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skin growth removal provided on 
January 18, 2023. 
 
You asked the Plan to waive the copayment for the skin growth removal. You say that you do not think the 
services you received should be considered 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 for outpatient sugery at an outpatient hospital facility. 
 
You have been asked to pay a $350 copayment for the skin growth removal. This item/service falls within the 
outpatient sugery at an 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. According to Medicare the skin growth removal (code 17000) is 
considered outpatient surgery. However, since the allowed amount is less than the standard copayment, you 
only owe $204.67. Therefore, we decided that the Plan does not have to waive the copayment for the skin 
growth removal provided on January 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on September 
15, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. 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 $305 
copayment for ambulance services. 
 
You have been asked to pay a $305 copayment for ambulance services. 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. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the lab services provided by an in-network 
provider on January 11, 2023. 
 
You asked the Plan to waive the coinsurance for the lab services. You say that you have never had to pay for 
these services before. 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 25% 
coinsurance for in and out-of-network blood and laboratory services. 
 
 
 You have been asked to pay a $154.35 coinsurance for the lab services because the allowed amount for each 
service is less than the 25% coinsurance. These items/services fall 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 coinsurance for 
the lab services provided by an in-network provider on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 15, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound debridement services provided 
on January 11, 2023. 
 
You asked the Plan to waive the copayment for the wound debridement services. You say that you were not 
told about this copayment 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 a $200 
copayment for outpatient surgery. 
 
You have been asked to pay a $200 copayment for the wound debridement services. This item/service falls 
within the outpatient surgery 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. According to Medicare the wound debridement (code 97597) is considered outpatient 
surgery. Therefore, we decided that the Plan does not have to waive the copayment for the wound debridement 
services provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram, ultrasound, 
and tomosynthesis provided on December 28, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram, ultrasound, and tomosynthesis. 
You say that these should be covered in full by your insurance. 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 $75 
copayment for each diagnostic radiology service.  
 
You have been asked to pay a $75 copayment for the diagnostic mammogram. You have also been asked to 
pay a $75 copayment for the ultrasound. You have also been asked to pay $22.82, which is less than the standard $75 copayment for the tomosynthesis. These items/services fall within the outpatient diagnostic tests 
and therapeutic services benefit category. You have been asked to pay a total of $172.82 ($75 copayment + $75 
copayment + $22.82 copayment = $172.82). 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 
diagnostic mammogram, ultrasound, and tomosynthesis provided on December 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite - one surface posterior (D2391) 
and endodontic therapy, molar tooth (excluding final restoration) (D3330) and pay for limited oral evaluation - 
problem focused (D0140) provided on January 13, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you paid the full amount for services; 
therefore, you should be fully reimbursed. 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. This benefit includes the 
requested limited oral evaluation - problem focused (D0140) but is limited to one procedure code per calendar 
year. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered limited oral 
evaluation - problem focused (D0140) on January 4, 2023. Therefore, these benefits were exhausted as of 
January 13, 2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - 
problem focused (D0140) provided on January 13, 2023. 
 
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 resin-based composite - one surface 
posterior (D2391) and endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on 
January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a crown - porcelain/ceramic (D2740) 
provided on February 21, 2023. 
 
You asked the Plan to waive the coinsurance for the crown - porcelain/ceramic. You say that you were 
informed you had no dental coverage and you were unable to change your provider as the services were already 
rendered. 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 70% 
coinsurance for non-Medicare covered comprehensive dental when provided out-of-network. 
.  
 You have been asked to pay a 70% coinsurance for the crown - porcelain/ceramic. This service falls within the 
non-Medicare covered comprehensive dental services when provided out-of-network  benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for a crown - porcelain/ceramic (D2740) provided on February 
21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve acupuncture services. You say that you need acupuncture in order to be able 
to work. The Plan denied your request. The Plan says there are other providers who can perform these services 
for you who are in-network. 
 
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 acupuncture services to be provided by an out-of-network (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 
October 10, 2022, to October 14, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you have never had to 
make such a large copayment before. 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 $180 copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says 
that you then pay a $0 copayment per day after day five of the same inpatient stay. 
 
You have been asked to pay a $180 copayment per day for days 1-4 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged for the day you 
were discharged. You have been asked to pay a total of $720 ($180 copayment per day x 4 days = $720). 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 inpatient hospital stay provided from October 10, 2022, 
to October 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 08, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services should be covered. 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 psychotherapy provided 
on December 08, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) scan of the thorax provided on 
October 31, 2022. 
 
You asked the Plan to pay for computed tomography (CT) scan of the thorax. You say that the enrollee was 
seen for an abormal x-ray lung nodule. You would like reconsideration based on the records submitted. 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 computed tomography 
(CT) scan of the thorax provided on October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystoscopy provided on December 21, 
2022. 
 
You asked the Plan to waive the copayment for the cystoscopy. You say that you would like to appeal the 
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 $350 
copayment for in-network outpatient surgery provided at an outpatient hospital facility. 
 
You have been asked to pay a $350 copayment for the cystoscopy. This item/service falls within the in-network outpatient surgery provided at an 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 the cystoscopy provided on December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the specialist office visit provided on 
December 21, 2022. 
 
You asked the Plan to reduce the deductible for the specialist office visit. You say that you would like this 
service to be reprocessed at the in-network benefit level. 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 $750 deductible which applies to out-of-network 
physician/practitioner services, including doctor's office visits. Your contract with the Plan also says there is a 
40% coinsurance once the deductible has been met for out-of-network Medicare-covered physician specialist 
services. You have been asked to pay $184.35 towards your deductible for the specialist office visit. The item or service 
you asked the Plan to reduce the deductible for falls within the physician/practitioner services, including 
doctor's office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $750 deductible which applies to out-of-network physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
the specialist office visit was received on December 21, 2022. Therefore, we decided that the Plan does not 
have to reduce the deductible for the specialist office visit provided on December 21, 2022.