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

 
We decided that the Plan does not have to waive the deductible for the office visit and the blood draw provided 
on May 5, 2023. 
 
You asked the Plan to waive the deductible for the office visit and the blood draw. You say that you would like 
the Plan to cover more for the services. 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 $675 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
 
 You have been asked to pay $139.71 towards the deductible for the office visit and the blood draw. The items 
or services you asked the Plan to waive the deductible for fall within the physician/practitioner services, 
including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $675 deductible which applies to physician/practitioner services, including doctor's 
office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit and 
the blood draw. was received on May 5, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for the office visit and the blood draw provided on May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization (36247, 36246). 
 
You asked the Plan to pre-approve genicular artery embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria 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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is little evidence in the medical literature to suggest that this is an 
appropriate procedure to be used for the treatment of knee arthritis. The review has determined that the 
items/services at issue in this case are not medically reasonable or 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization (36247, 36246).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - three surfaces, anterior (D2332) 
provided on June 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you gave your insurance card to the dental 
office and they told you they accepted your dental plan and took a copayment. The Plan denied your request. 
The Plan says the dental services were received from an out-of-network provider and are not covered by your 
supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested service is not covered under this benefit 
when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
the resin-based composite - three surfaces, anterior (D2332) provided on June 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on July 06, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you are asking for your copayment 
back because the doctor doesnt do the procedure that you need. 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 for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for an 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 an office visit provided on July 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placements of implant body: endosteal implant 
(D6010), extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), immediate 
denture - maxillary (D5130), and immediate denture - mandibular (D5140) provided on March 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are asking for reimbursement for this dental 
claim. You also say that you went  back to the dentist and requested the information that was requested. The 
Plan denied your request. The Plan says these services are not covered under your dental 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 
surgical placements of implant body: endosteal implant (D6010), extractions, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140), immediate denture - maxillary (D5130), and immediate denture - 
mandibular (D5140) provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on May 10, 2023. 
 
You asked the Plan to pay for a home visit. You say that the enrollee was in a nursing facility and should not 
have needed a referral or authorization. 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 home visit provided on 
May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740), and core buildup, 
including any pins when required (D2950) provided on May 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider indicated that you had enough of 
your annual maximum to cover the services. The Plan denied your request. The Plan says your benefit for the 
requested item or service $1,500 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 $1,500 towards the cost of dental services provided in 2023. Therefore, we decided that the 
Plan does not have to pay for the crown - porcelain/ceramic (D2740), and core buildup, including any pins 
when required (D2950) provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 17, 2023. 
 
You asked the Plan to pay for an office visit. 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 provided 
on March 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 08, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are requesting 
reconsideration stating that the member was transported to and from dialysis and you have submitted medical 
documentation to support. 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. However, since the allowed amount is less than the standard copayment, you only owe $219.48. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on 
March 08, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested drug is necessary for the enrollee's 
current condition. The Plan denied your request. The Plan says the use for the requested drug does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that the 
requested drug does not meet the criteria for approval. Our physician reviewer found Botox is not standard of 
care for the enrollee's condition. There is insufficient medical evidence to support its use in this clinical 
scenario and does not meet the LCD criteria for coverage. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each foot x-ray provided on April 05, 2023, 
to April 26, 2023. 
 
You asked the Plan to waive the copayment for each foot x-ray. You say that you do not agree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for each basic imaging service including x-rays. 
 
You have been asked to pay a $25 copayment for each foot x-ray. This item/service falls within the each basic 
imaging service including x-rays 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 amount you owe is $50 ($25 copayment x 2 services = $50). 
Therefore, we decided that the Plan does not have to waive the copayment for each foot x-ray provided on 
April 05, 2023, to April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D5214). 
 
You asked the Plan to pre-approve the dental service (D5214). You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. 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 February 4, 2022. 
Therefore, we decided that the Plan does not have to pre-approve the dental service (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiographic/surgical implant index and consultation 
(D6190, D9310) provided on July 20, 2023. 
 
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 the services 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, 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 a 
radiographic/surgical implant index and consultation (D6190, D9310) provided on July 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office (D9630) 
provided on March 23, 2023. 
 
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 the services 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 Plan's 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 drugs or 
medicaments dispensed in the office (D9630) provided on March 23, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiography provided on June 08, 2023. 
 
You asked the Plan to pay for echocardiography. You say that you are requesting reconsideration asking for the 
attached medical records to be reviewed. 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 echocardiography 
provided on June 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210) provided on June 19, 2023. 
 
You asked the Plan to pay for the intraoral  comprehensive series of radiographic images. You say that you 
only went to get antibiotics for an infected tooth and received more services than you were comfortable with. 
The Plan denied your request. The Plan says your benefit for the requested 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 service was exhausted on date of service May 29, 2019. Therefore, we 
decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210) provided on June 19, 2023.  
 
Your complaint about your experience with the dentist office is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for genetic testing provided on November 14, 
2022. 
 
You asked the Plan to waive the coinsurance for genetic testing. You say that you need help with paying the 
coinsurance. 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 provided in all service settings. 
 
You have been asked to pay 20% coinsurance for genetic testing. This item/service falls within the in-network 
genetic testing provided in all service settings 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 Plan is only holding you responsible for a $64.85 coinsurance which is 
less than a 20% coinsurance. Therefore, we decided that the Plan does not have to waive the coinsurance for 
genetic testing provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - comprehensive series of radiographic images 
(D0210), a comprehensive oral evaluation (D0150), and an adult prophylaxis (D1110) provided on May 26, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the provider confirmed they work with your 
Plan. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for intraoral - comprehensive series of radiographic images (D0210), a comprehensive oral evaluation 
(D0150), and an adult prophylaxis (D1110) provided on May 26, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Cemiplimab-rwlc injections provided 
on March 24, 2023, to May 26, 2023. 
 
You asked the Plan to waive the copayment for the Cemiplimab-rwlc injections. You say that you do not agree 
with the cost share for the injections. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for Medicare Part B prescription drugs.  
 
  The enrollee has been asked to pay a total of $7,119.03 for the Cemiplimab-rwlc injections.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
March 24, 2023 Cemiplimab-rwlc 
injections 
$8,919.92 20% $1,783.98 
April 14, 2023 Cemiplimab-rwlc 
injections 
$8,891.75 20% $1,778.35 
May 5, 2023 Cemiplimab-rwlc 
injections 
$8,891.75 20% $1,778.35 
May 26, 2023 Cemiplimab-rwlc 
injections 
$8,891.75 20% $1,778.35 
TOTAL:    $7,119.03 
 
This item/service falls within the Medicare Part B prescription drugs benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the Cemiplimab-rwlc injections provided on March 24, 2023, to May 
26, 2023.