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

 
We decided that the Plan does not have to pay for the office visit and services provided on October 5, 2023, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and services. You say that after your appointment was cancelled 
twice you were offered to see another physician. The Plan denied your request. The Plan says the services were 
not emergent and there was no prior authorization. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the office visit and services provided on October 5, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the routine cleaning (D1110), 4 fillings (D2330), 
and retainer crown (D6740) provided on August 30, 2023, in a foreign country. 
 
You asked the Plan to reimburse you for the dental services. You say that you were traveling out of the country 
when you broke a tooth. You say that you needed to receive emergency care. You also say that you had 
restoration of resin and a cleaning done. The Plan denied your request. The Plan says dental services received 
outside of the United States are not covered. 
 
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 dental services received outside of 
the United States are not among those covered under this benefit. Additionally, there are no medical records to 
support that the services were urgent or emergent in nature. Therefore, we decided that the Plan does not have 
to reimburse you for the routine cleaning (D1110), 4 fillings (D2330), and retainer crown (D6740) provided on 
August 30, 2023, in a foreign country.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on August 17, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that the amount allowed by the Plan is no the 
expected amount, per your contract. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 nursing facility care provided on August 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the oral exam (D0120), prophylaxis (D1110), 
periapical x-rays (D0220 x 2), crown (D2740), and palliative treatment of dental pain (D9110) provided from 
May 31, 2023, to September 26, 2023, by an out-of-network dentist. 
 
You asked the Plan to pay more for the dental services. You say that your plan covers 2 dental cleanings and x-
rays per year and $2,000 towards dental work. You also say that you feel you should not be responsible for the 
bills that you received. 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 the oral exam (D0120), prophylaxis 
(D1110), periapical x-rays (D0220 x 2), crown (D2740), and palliative treatment of dental pain (D9110) 
provided from May 31, 2023, to September 26, 2023, by an out-of-network dentist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
August 20, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The record does not indicate the enrollee is on insulin or have a 
history of problematic hypoglycemia. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a 
continuous glucose monitor (CGM) (A4239) provided on August 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the office visit provided on September 30, 
2023. 
 
You asked the Plan to reduce the copayment for the office visit. You say that you are asking for the reduction 
of the $40 copayment to a $10 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 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 reduce the copayment for the office visit provided on September 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on July 18, 
2023. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you were taken to the 
emergency room and hospitalized. You feel you should not need to pay these copayments. 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 $275 
copayment for ambulance services. 
 
You have been asked to pay a $275 copayment for an ambulance ride. 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 an ambulance ride 
provided on July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete denture - maxillary (D5110), and 
unspecified removable prosthodontic procedure, by report (D5899) provided on August 23, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you had past experiences with dentures 
being covered by previous insurance. The Plan denied your request. The Plan says your benefit for the 
requested dental services $1,000 dollar limit was met. The Plan also says dental service D5899 is not included 
in your dental coverage. 
 
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 dental services was exhausted on dates of service August 8, 2023 and the appealed 
claim. This included a partial payment of $928.50 towards the services provided on August 23, 2023. Once this 
partial payment was made, the yearly benefit maximum was reached. The unspecified removable prosthodontic 
procedure, by report (D5899) is not among those covered under this benefit Therefore, we decided that the Plan 
does not have to pay more for the complete denture - maxillary (D5110), and unspecified removable 
prosthodontic procedure, by report (D5899) provided on August 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
November 19, 2022, to November 22, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the 3 day hospital stay 
was not your fault and you should not be responsible for this balance. 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 $325 
copayment for inpatient hospital care.  
You have been asked to pay a $325 copayment for the inpatient hospital stay. 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. You have been asked to pay a total of $975 for the inpatient hospital stay ($325 copayment 
x 3 days = $325). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on November 19, 2022, to 
November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation - established patient 
(D0120), topical application of fluoride varnish (D1206), periodontal maintenance (D4910), and inhalation of 
nitrous oxide/analgesia, anxiolysis (D9230) provided on October 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you should not be responsible for these 
services. You also say that you were unaware that you had exhausted your $1,000 annual benefit. The Plan 
denied your request. The Plan says your benefit for the requested dental services $1,000 dollar limit was met. 
 
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 dental services has been exhausted. The Plan has provided evidence of having made 
payments totaling $1,000 towards the cost of dental services provided in 2023. This included a partial payment 
of $19.20 towards the services in dispute. Once this partial payment was made, the yearly benefit maximum 
was reached. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation - 
established patient (D0120), topical application of fluoride varnish (D1206), periodontal maintenance (D4910), 
and inhalation of nitrous oxide/analgesia, anxiolysis (D9230) provided on October 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
August 18, 2023, to August 20, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you spent the entire 
time in ER an you were never given a room. 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 $250 
copayment for inpatient hospital care.  
You have been asked to pay a $250 copayment for the inpatient hospital stay. 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. You have been asked to pay a total of $500 for the inpatient hospital stay ($250 copayment 
x 2 days = $250). You have not been charged for the day you were discharged. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital stay provided on August 18, 2023, to 
August 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the compression stockings identified with 
code A6530 that were issued on August 3, 2023. 
 
You asked the Plan to issue reimbursement for the compression stockings. 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 covered by Medicare.  
  
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to issue reimbursement for the 
compression stockings identified with code A6530 that were issued on August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office visit provided on August 24, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the new patient office visit. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the new patient office visit provided on August 24, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 20, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 laboratory services provided on June 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient hospital stay on October 21, 
2022, to November 1, 2022.  
 
You asked the Plan to waive the cost share for the inpatient hospital stay. 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 $310 
copayment per day, per admission for days 1-7 and a $0 copayment per day, per admission for days 8-90 for 
inpatient hospital care. You were admitted to the hospital for 11 days, which would be a $2,170.00 copayment 
($310.00 x 7 days). However, the 2022 out-of-pocket maximum was met and assessed the lower amount of 
$1,790. Therefore, results in the total cost sharing amount of $1,790. 
 
You have been asked to pay a $1,790 cost share for the inpatient hospital stay. 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 cost share for the inpatient 
hospital stay on October 21, 2022, to November 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lymphatic system imaging provided on 
March 29, 2023. 
 
You asked the Plan to waive the copayment for the lymphatic system imaging. You say that you were told you 
had to have these images done in order to have surgery. You say that you only expected one big copayment not 
two. 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 diagnostic tests. 
 
You have been asked to pay a $350 copayment for the lymphatic system imaging. This item/service falls within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
lymphatic system imaging provided on March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alert or alarm device (A9280). 
 
You asked the Plan to pre-approve an alert or alarm device. You say that the item is necessary. The Plan denied 
your request. The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an alert or alarm device (A9280).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 14, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the office visit provided on June 14, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjunctive general services (code D9999) provided on  
July 19, 2023. 
 
You asked the Plan to pay for adjunctive general services. The Plan denied your request. The Plan says 
adjunctive general services is not a covered dental 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for adjunctive 
general services (code D9999) provided on July 19, 2023.