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

 
We decided that the Plan does not have to pre-approve an additional transportation trip. 
 
You asked the Plan to pre-approve the additional transportation trip. You say that the services are medically 
necessary for you to pick up your medication and get your blood pressure checked. The Plan denied your 
request. The Plan says you have exhausted your maximum benefit for the year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when 48.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional transportation trip.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network hand x-ray provided on May 
25, 2023. 
 
You asked the Plan to waive the deductible for an in-network hand x-ray. You say that you should not have 
such a large charge, it should only be a $20 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. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient hospital services.  
 
You have been asked to pay $76.26 towards your $750 deductible for 2023. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient hospital services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to outpatient hospital services.  This cost sharing is a contractual obligation that had not been met at the time an in-network hand x-ray was 
received on May 25, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an in-
network hand x-ray provided on May 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a joint injection provided on March 16, 
2023. 
 
You asked the Plan to waive the copayment for a joint injection. You say that you do not feel that you should 
have to pay. 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 in-network outpatient surgery provided an outpatient hospital facility. 
 
You have been asked to pay a $200 copayment for a joint injection. This item/service falls within the in-
network outpatient surgery provided 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 a joint injection provided on March 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network magnetic resonance imaging  
(MRI) scan provided on April 17, 2023. 
 
You asked the Plan to waive the copayment for an in-network magnetic resonance imaging  (MRI) scan. You 
say that this copayment is too costly for you. 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 $225 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $225 copayment for an in-network magnetic resonance imaging  (MRI) scan. 
This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an in-network magnetic resonance imaging  
(MRI) scan provided on April 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit, and related services 
provided on May 31, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit, and related services. You say that this is 
supported in the records. 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 a hospital outpatient 
clinic visit, and related services provided on May 31, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance provided on February 27, 2023. 
 
You asked the Plan to pay for ambulance. You say that you say that there were no other transport appropriate 
for this patient. 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 ambulance provided on 
February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87633 and 87634, provided 
on February 27, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. Respiratory panels with more than 5 respiratory pathogens performed in the Part B 
outpatient setting are considered not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Also, respiratory 
panels with more than 5 respiratory pathogens performed in the Part B outpatient setting are considered not 
medically reasonable and necessary. Further, a respiratory pathogen panel test must not be unbundled and 
billed as individual components regardless of the fact that the panel reports multiple individual pathogens 
and/or targets. Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 
87633 and 87634, provided on February 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry services provided on May 23, 
2023. 
 
You asked the Plan to waive the copayment for the podiatry services. You say that you did not have to pay a 
copayment for this service in the past. 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 
copayment for podiatry services. 
 
You have been asked to pay a $25 copayment for the podiatry services. This item/service falls within the 
podiatry 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 the podiatry services 
provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crowns  
(D6065 x 3) and prefabricated abutments-includes modification and placement (D6056 x 3).  
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested dental items are not covered under the 
supplemental dental policy.  
 
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 are not among 
those covered under this benefit.   
 
 
Therefore, we decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crowns 
(D6065 x 3) and prefabricated abutments-includes modification and placement (D6056 x 3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PILD.  
 
You asked the Plan to pre-approve the PILD. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 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 the PILD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that PILD is considered experimental/investigational and is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PILD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PILD.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two in-network acupuncture visits. 
 
You asked the Plan to pay for two in-network acupuncture visits. You say that the visits being counted were for 
2022, not 2023. You did not hit the limit yet. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. There are records showing you already hit the acupuncture cap for 2023.  
 
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 $95 
payment for acupuncture for chronic low back pain.  
 
You have been asked to pay a $190 total payment for two in-network acupuncture visits ($95 x 2 = $190). This 
item/service falls within the acupuncture for chronic low back pain 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 pay for two in-network acupuncture visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychology visit provided on December 07, 2022. 
 
You asked the Plan to pay for a psychology visit. You say that the patient did not tell you the type of plan they 
had, and you would like this claim to be reassessed. 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 a psychology visit 
provided on December 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full cast high noble metal crown on tooth 18(D2790). 
 
You asked the Plan to pre-approve the dental services. You say that the last crown you had kept coming out 
and you needed a new one. 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 March 24, 2022. 
Therefore, we decided that the Plan does not have to pre-approve full cast high noble metal crown on tooth 18(D2790).
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 
April 20, 2023, to April 25, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel that the extra 
days you spent as inpatient were out of your control. 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 $375 
copayment each day for days 1 to 5, for inpatient hospital care. 
 
 You have been asked to pay a $1500 copayment for the inpatient hospital stay ($375 copayment x 4 days = 
$1500). 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 waive the copayment for the inpatient hospital stay provided from April 20, 2023, to April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on April 19, 2023. 
 
You asked the Plan to pay for the core buildup. You say that you called prior to the date of service and was 
advised that crowns are covered under your $5,000.00 annual maximum. The Plan denied your request. The 
Plan says there is no coverage for core buildup. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, 
including any pins when required (D2950) provided on April 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the nuclear stress test provided by an in-
network provider on January 20, 2023. 
 
You asked the Plan to waive the cost sharing for the nuclear stress test. You say that you are being wrongfully 
billed. 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 $500 deductible which applies to the nuclear stress test, and that you 
must pay a $180 copayment for in-network advanced imaging services provided in all places of service. 
 
 You have been asked to pay a $180 copayment for the nuclear stress test. You have also been asked to pay a 
$500 deductible for the nuclear stress test. The item or service you asked the Plan to waive the cost sharing for 
falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to 
outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation 
that had not been met at the time the nuclear stress test was provided on January 20, 2023. Therefore, we 
decided that the Plan does not have to waive the cost sharing for the nuclear stress test provided by an in-
network provider on January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts-of a retained natural tooth-first 
site in quadrant (D4263 x 3) and surgical placement of an implant body: endosteal implants (D6010 x 3). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
supplemental dental policy.  
 
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 services are not among 
those covered under this benefit.  
  
 
 
 
 
 
Therefore, we decided that the Plan does not have to pre-approve bone replacement grafts-of a retained natural 
tooth-first site in quadrant (D4263 x 3) and surgical placement of an implant body: endosteal implants  
(D6010 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement 
(D6057) and abutment supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve custom fabricated abutment and abutment supported porcelain/ceramic 
crown. You say that this is medically necessary. 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 pre-approve custom fabricated abutment  includes placement (D6057) and abutment supported porcelain/ceramic crown 
(D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids.  
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are network providers available to render the 
requested items in this case.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when prescribed by a network provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when prescribed by a network provider. However, the hearing aids in this case were requested to be 
provided by an out-of-network vendor. Therefore, we decided that the Plan does not have to pre-approve 
hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 19, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on April 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim complete dentures maxillary (D5810), and 
mandibular (D5811). 
 
You asked the Plan to pre-approve the temporary dentures. You say that due to osteoporosis all your teeth are 
busting off in your mouth and they need to be removed. You also say that you have achalasia which is a life-
threatening condition. The Plan denied your request. The Plan says temporary dentures are not a covered 
benefit under your benefit 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve interim 
complete dentures maxillary (D5810), and mandibular (D5811).