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

 
We decided that the Plan does not have to pay for an additional intraoral x-ray, inhalation of nitrous 
oxide/analgesia, provisional crown, core buildup services, extraction, bone replacement graft, prefabricated 
post and core, retainer crown, and pontics (D0220, D9230, D2799, D2950, D7210, D7953, D2954, D6750, 
D6240, D6242) provided on November 3, 2022, to November 9, 2022. 
 
  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 intraoral x-ray was exhausted on 
the appealed claim. Coverage for the inhalation of nitrous oxide/analgesia, provisional crowns, core buildup 
services, extractions, bone replacement grafts, prefabricated post and cores, retainer crowns, and pontics 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 9, 2022. The 
inhalation of nitrous oxide/analgesia, provisional crowns, core buildup services, extractions, bone replacement 
grafts, prefabricated post and cores, retainer crowns, and pontics are not among those covered. Therefore, we 
decided that the Plan does not have to pay for an additional intraoral x-ray, inhalation of nitrous 
oxide/analgesia, provisional crown, core buildup services, extraction, bone replacement graft, prefabricated 
post and core, retainer crown, and pontics (D0220, D9230, D2799, D2950, D7210, D7953, D2954, D6750, 
D6240, D6242) provided on November 3, 2022, to November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 16, 2022, to December 
12, 2022. 
 
You asked the Plan to pay for an office visit. You say that you want this to be reviewed, it 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 16, 2022, to December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmologist office visit provided 
on January 23, 2023. 
 
You asked the Plan to waive the copayment for the ophthalmologist office visit. You say that a previous 
appointment was canceled and you should not have to pay for this visit. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the ophthalmologist office visit. This item/service falls within 
the specialist physician/practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. The record shows this claim was approved and you are responsible for the 
cost share amount. Therefore, we decided that the Plan does not have to waive the copayment for the 
ophthalmologist office visit provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on October 18, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration for 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on October 18, 2022.
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 December 22, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you have a 
10% copayment. You also say that this was an emergency. The Plan denied your request. The Plan says these 
services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 22, 2022. 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 December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 19, 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 December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on November 21, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
November 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on December 06, 2021. 
 
You asked the Plan to pay for wound care. You say that you are appealing the claim payment denial. 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 wound care provided on 
December 06, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
December 8, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were rendered by an out-of-network provider.  
 
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 purchased from the Plans select hearing aid 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 covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on December 8, 2022.
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 
February 22, 2023, to February 27, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you had to remain 
inpatient to resolve internal bleeding caused by the hospital. 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 $395 
copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 of in-network inpatient care.  
 
 You have been asked to pay a $395 copayment per day for days 1 to 5 of the inpatient hospital stay. You have 
been asked to pay a total of $1,975 ($395 copayment x 5 days = $1,975). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient hospital stay provided from February 22, 2023, to 
February 27, 2023.  
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the mental health visit provided on January 
12, 2023. 
 
You asked the Plan to reduce the copayment for the mental health visit. You say that you should only have a 
$35 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 $85 
copayment for outpatient hospital services, including mental health services. 
 
You have been asked to pay a $85 copayment for the mental health visit. This item/service falls within the outpatient hospital services, including mental health services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The records show the services were provided by an 
outpatient hospital, and the outpatient hospital copayment applies. Therefore, we decided that the Plan does not 
have to reduce the copayment for the mental health visit provided on January 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the replacement of the brain 
neurostimulator device provided on January 17, 2023. 
 
You asked the Plan to waive the copayment for the replacement of the brain neurostimulator device. You say 
that you had no choice but to use the facility. 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 $95 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. 
 
You have been asked to pay a $95 copayment for the replacement of the brain neurostimulator device. This item/service falls within the outpatient surgery and other medical services provided at hospital outpatient 
facilities 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 replacement of the 
brain neurostimulator device provided on January 17, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on February 18, 
2022, to March 04, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you are not able to afford the cost 
share applied. 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. 
 
You have been asked to pay 20% coinsurance for chemotherapy. 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. The total you owe is $2,827.29, which is 20% of the allowed amount for chemotherapy. 
Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy provided on 
February 18, 2022, to March 04, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mental health visit provided on 
November 01, 2022. 
 
You asked the Plan to waive the copayment for the mental health visit. You say that you should only have a 
$40 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 $100 
copayment for outpatient hospital services, including mental health services. 
 
You have been asked to pay a $100 copayment for the mental health visit. This item/service falls within the outpatient hospital services, including mental health services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The records show the services were provided by an 
outpatient hospital, and the outpatient hospital copayment applies. Therefore, we decided that the Plan does not 
have to waive the copayment for the mental health visit provided on November 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial lower dentures (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 January 28, 2022. 
Therefore, we decided that the Plan does not have to pre-approve partial lower dentures (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the specialist visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the specialist visits. You say that you feel comfortable seeing this provider. 
The Plan denied your request. The Plan says you must get your care from network providers. 
 
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 specialist visits 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. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on February 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on August 
03, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. 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 $360 
copayment for in-network ambulance services. 
 
You have been asked to pay a $360 copayment for the ambulance services. This item/service falls within the 
in-network 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. However, since the allowed amount is less than the standard copayment, you 
only owe $277.50. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance services provided on August 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and related services provided on June 03, 
2022. 
 
You asked the Plan to pay for an office 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 an office visit, and 
related services provided on June 03, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on December 21, 2022. 
 
You asked the Plan to pay for laboratory testing. 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 laboratory testing 
provided on December 21, 2022.