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

 
We decided that the Plan does not have to waive the copayment for the office visit, and the spine x-rays 
provided by an in-network provider on April 18, 2023. 
 
You asked the Plan to waive the copayment for the office visit, and the x-rays. You say that you thought that 
these services were covered. 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 $35 
copayment per day, per provider, for in-network Medicare-covered x-ray services, and a $45 copayment for 
each in-network Medicare-covered visit with a specialist. 
 
You have been asked to pay a $35 copayment for the x-rays. These items/services fall within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay a $45 
copayment for the office visit. This item/service falls within the physician/practitioner services, including 
doctors office visits 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 office visit, and 
the spine x-rays provided by an in-network provider on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5298) provided on March 16, 2022. 
 
You asked the Plan to pay for a hearing aid (V5298). You say that you believe you should be reimbursed as 
you have the hearing aid benefit. The Plan denied your request. The Plan says items are to be supplied by Plan 
hearing network providers. 
 
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 they are obtained from a Plan hearing network vendor. 
 
We looked at the file and the Plan's rules. The record shows the hearing aids (V5298) were obtained by a 
vendor who was not a Plan hearing network vendor. Based on this information, we decided that the Plan's rules 
for coverage of a hearing aid (V5298) have not been met. Therefore, we decided that the Plan does not have to 
pay for a hearing aid (V5298) provided on March 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on May 
17, 2023. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. 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 $50 
copayment for emergency care. 
 
You have been asked to pay a $50 copayment for emergency room services. This item/service falls within the 
emergency 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 emergency room services 
provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network electrocardiogram (ECG) 
provided on  March 30, 2023. 
 
You asked the Plan to waive the copayment for an ECG. You say that you had already paid a copayment for 
the office visit. You paid this $15 charge but want it refunded as you do not know why it is there. 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 $50 
copayment for other outpatient diagnostic tests - non-radiological diagnostic services.  
 
You have been asked to pay the allowed amount of $15.29 which is less than the $50 copayment for an ECG. This item/service falls within the other outpatient diagnostic tests - non-radiological diagnostic 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 an in-network electrocardiogram (ECG) 
provided on  March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on April 
18, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this service is non-covered and not payable. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the refraction is part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that a refraction is only covered when performed 
during a routine vision examination. The Plan rules also say that Original Medicare does not cover routine eye 
refractions for eyeglasses/contacts. The record shows that this was a medical/diagnostic refraction. Based on 
this information, we decided that the Plan's rules for coverage of a determination of refractive state (92015) 
have not been met. Therefore, we decided that the Plan does not have to pay for a determination of refractive 
state (92015) provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiography provided on February 22, 
2023. 
 
You asked the Plan to pay for the transthoracic echocardiography. 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 transthoracic 
echocardiography provided on February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for genetic testing provided on March 17, 
2023. 
 
You asked the Plan to waive the coinsurance for genetic testing. You say that you think that this service was 
denied. 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 in-network genetic testing. 
 
You have been asked to pay 20% coinsurance for genetic testing. This item/service falls within the in-network 
genetic testing 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 $720 ($3600 allowed amount x 20% = $720). Therefore, we decided that the Plan 
does not have to waive the coinsurance for genetic testing provided on March 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital, binaural hearing aids (V5261) provided on April 4, 
2023. 
 
You asked the Plan to pay for digital, binaural hearing aids (V5261). You say that you did not know you had to 
go to a specific provider. The Plan denied your request. The Plan says your mandatory supplemental hearing 
plan only covers in-network providers that are contracted through the Plan specific vendor. 
 
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 you obtain the hearing aids through a Plan specific vendor.  
 
 
  We looked at the file and the Plan's rules. The Plan rules say that the Plan covers up to 2 Plan specific vendor 
hearing aids every year (1 per ear, per year). The Plan rules also say that you must see a Plan specific vendor to 
use this benefit. The record shows that you did not see a Plan specific vendor, and went out-of-network. Based 
on this information, we decided that the Plan's rules for coverage of digital, binaural hearing aids (V5261) have 
not been met. Therefore, we decided that the Plan does not have to pay for digital, binaural hearing aids 
(V5261) provided on April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision supply or accessory (V2797) provided on June 20, 
2023. 
 
You asked the Plan to pay for vision supply or accessory (V2797). You say that you were informed on January 
4, 2023, of the benefits you could use from January 1, 2023, which include dental, vision and hearing. The Plan 
denied your request. The Plan says this service is not covered by the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye examination every year and up to $100 for eyeglasses or contacts 
every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one routine eye examination 
every year and up to $100 for eyeglasses or contacts every two years. Vision supplies or accessories (V2797) 
are excluded from this benefit. Based on this information, we decided that the Plan's rules for coverage of 
vision supply or accessory (V2797) have not been met. Therefore, we decided that the Plan does not have to 
pay for vision supply or accessory (V2797) provided on June 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on November 23, 2022. 
 
You asked the Plan to pay for the panel testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the panel testing provided on November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy provided on 
May 22, 2023. 
 
You asked the Plan to waive the copayment for a fine needle aspiration biopsy. You say that you feel that the 
copayment has been applied incorrectly for the type of procedure performed. 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 $150 
copayment for in-network surgery performed in an outpatient hospital setting. 
 
You have been asked to pay a $150 copayment for a fine needle aspiration biopsy. This item/service falls 
within the in-network surgery performed in an outpatient hospital setting 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 fine needle aspiration biopsy provided on May 22, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on May 03, 2023. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. 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 $260 
copayment for ambulance services. 
 
You have been asked to pay a $260 copayment for ambulance. 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 provided on 
May 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) provided on November 1, 2022. 
 
You asked the Plan to reimburse for hearing aids (V5298). You say that  you called the Plan and were asked by 
a Plan representative if you had gone through the Plan hearing to obtain the hearing aids. You also say that you 
had not because you were not aware of that department, since it did not exist when you previously purchased 
hearing aids. The Plan denied your request. The Plan says the Plan benefits state that hearing aids ordered 
through providers other than the Plan hearing are not covered. 
 
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 they are obtained through an in-network provider.  
 
 
  We looked at the file, and the Plan's rules. The rules say you must use an in-network Plan hearing provider. The 
record shows that you obtained your hearing aids through an out-of-network provider. Based on this 
information, we decided that the Plan's rules for coverage of hearing aids (V5298) have not been met. 
Therefore, we decided that the Plan does not have to reimburse for hearing aids (V5298) provided on 
November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic visit provided on March 14, 2023. 
 
You asked the Plan to pay for chiropractic visit. You say that you had to see an out-of-network provider, 
because you have no in-network providers near you. 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 chiropractic visit 
provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (D9215) provided on May 24, 2023. 
 
You asked the Plan to pay for the dental service. You say that it was medically necessary for you to get the 
anesthesia with the dental surgery. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the anesthesia 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 pay for the 
anesthesia (D9215) provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
May 2, 2023. 
 
You asked the Plan to pay for D4341. You say that you need this level of deep cleaning. The Plan denied your 
request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing (D4341) provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on June 13, 2022, through 
February 24, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered in full. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on June 13, 2022, 
through February 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on January 5, 2023. 
 You asked the Plan to pay for the eyeglasses. You say that you say your vision changed and needed stronger 
lens in order to have better vision. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan only covers a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the items are not covered supplemental benefits. Based 
on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses provided on January 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a foot surgery provided on August 11, 2022. 
 
You asked the Plan to pay for a foot surgery. 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 a foot surgery provided 
on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a diagnostic eye examination (92014) 
provided on April 10, 2023. 
 
You asked the Plan to reduce the copayment for a diagnostic eye examination (92014). You say that this is an 
annual routine vision examination, for which you are allowed a $15 copayment, and that is it. The Plan denied 
your request. The Plan says the records indicated that the visit was to treat/diagnose a problem with the eye. 
The Plan also says that per your Plan's benefit, you pay $45 for each Medicare-covered outpatient visit for 
services to diagnose and/or treat a disease or condition of the eye. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan says there is a $45 copayment for each Medicare-covered outpatient visit for services to 
diagnose and/or treat a disease or condition of the eye. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $45 for each Medicare-covered 
outpatient visit for services to diagnose and/or treat a disease or condition of the eye. The record shows this 
was a diagnostic eye examination. Specifically, the reason for the visit was blurred vision and ocular migraines. 
Based on this information, we decided that the Plan's rules for coverage of a diagnostic eye examination 
(92014) have not been met. Therefore, we decided that the Plan does not have to reduce the copayment for a 
diagnostic eye examination (92014) provided on April 10, 2023.