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

 
We decided that the Plan does not have to waive the coinsurance for the mammography service provided on 
July 10, 2023. 
 
You asked the Plan to waive the coinsurance for the mammography service. You say that the mammogram 
should have a $0 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 40% 
coinsurance for breast cancer screening (mammograms). 
 
You have been asked to pay 40% coinsurance for the mammography service. This item/service falls within the 
breast cancer screening (mammograms) 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 $40.73, which is 40% coinsurance of the 
allowed amount for each item. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the mammography service provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on May 3, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that the representative you spoke 
with on the phone advised you to submit a reconsideration claim with all the medical records. The Plan denied 
your request. The Plan says that the chiropractic manipulative treatment is available in network.  
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 chiropractic manipulative treatment provided on 
May 3, 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 panoramic radiographic image (D0330), 2D oral/facial 
photographic images obtained intraorally or extraorally (D0350) and intraoral-periapical each additional 
radiographic image (D0230) provided on June 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the panoramic radiographic image and the intraoral-periapical each 
additional radiographic image has already been exhausted. 2D oral/facial photographic images obtained 
intraorally or extraorally 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, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service November 4, 2020. 
The intraoral-periapical each additional radiographic image was exhausted on June 1, 2023. Therefore, we 
decided that the Plan does not have to pay for panoramic radiographic image (D0330), 2D oral/facial 
photographic images obtained intraorally or extraorally (D0350) and intraoral-periapical each additional 
radiographic image (D0230) provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for in-network injections provided on April 19, 2023. 
 
You asked the Plan to waive the cost for injections. You say that you are being charged extra copayments that 
you cannot afford. 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 physician/practitioner services, including doctors office visits, and a 20% coinsurance for 
Medicare Part B prescription drugs.  
 
 You have been asked to pay a $25.25 cost for injections. This item/service falls within the 
physician/practitioner services, including doctors office visits, and 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. Therefore, we 
decided that the Plan does not have to waive the cost for in-network injections provided on April 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for porcelain/ceramic crown (D2740), a periodic oral 
evaluation (D0120) and an adult prophylaxis (D1110) provided on January 12, 2023, to March 23, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you have had continuous coverage with 
the Plan since the policy inception and you do not fully understand these partial payments for covered dental 
expenses. 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 porcelain/ceramic crown (D2740), a periodic 
oral evaluation (D0120) and an adult prophylaxis (D1110) provided on January 12, 2023, to March 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 8, 2023, to July 
6, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you are seeking a review of the 
submitted records and to reconsider the claim for payment. The Plan denied your request. The Plan says the 
claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 8, 2023, to July 6, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), intraoral - 
periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image 
(D0230) provided on August 14, 2023. 
 
You asked the Plan to pay for 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 May 26, 2023. Therefore, 
we decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image 
(D0230) provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2332) for tooth #9 and #11 
provided on June 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were homebound, and it was necessary for 
you to have 2 fillings at once. The Plan denied your request. The Plan says your benefit for the requested items 
or services 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 the Plan paid for a resin-based composite (D2332) for tooth #9 and #11 on June 20, 2023; therefore, 
your benefit for the requested items or services was exhausted on the date of service of June 20, 2023. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2332) for tooth #9 and 
#11 provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network injection procedure 
provided on August 21, 2023. 
 
You asked the Plan to waive the coinsurance for an injection procedure. You say that you should not have to 
pay more than the $30 specialist copay, which you paid at the time of the visit. There should not be this extra 
charge. 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 $30 
copayment for physician/practitioner services, including doctors office visits, and a 20% coinsurance for 
Medicare Part B prescription drugs.  
 You have been asked to pay a $285.60 total cost for an injection procedure. This item/service falls within the 
physician/practitioner services, including doctors office visits and 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. Therefore, we 
decided that the Plan does not have to waive the coinsurance for an in-network injection procedure provided on 
August 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain fused to metal crown 
(D6066). 
 
You asked the Plan to pre-approve implant supported porcelain fused to metal crown. You say that this should 
be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant supported porcelain fused to metal crown (D6066).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 11, 2023, to July 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,000 annual maximum 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 $1,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on April 11, 2023, to July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take-home supply of methadone (G2078) and the 
medication assisted treatment (G2067) provided on April 10, 2023, by an OON provider.  You asked the Plan to pay for the take-home supply of methadone (G2078) and the medication assisted 
treatment (G2067). You say that you are requesting reconsideration of the denied claim. The Plan denied your 
request. The Plan says the service was 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 take-home supply of methadone (G2078) and 
the medication assisted treatment (G2067) provided on April 10, 2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network laboratory testing provided on 
July 10, 2023. 
 
You asked the Plan to waive the copayment for in-network laboratory testing. You say that you have this done 
yearly as part of your annual and do not have to pay a separate 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 $30 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $30 copayment for in-network laboratory testing. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for in-network laboratory testing provided on July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), lenses (V2783), variable asphericity lens 
(V2410), anti-reflective coating (V2750) and a routine eye examination (S0620) provided on April 26, 2023. 
 
You asked the Plan to pay for frames (V2020), lenses (V2783), variable asphericity lens (V2410), anti-
reflective coating (V2750) and a routine eye examination (S0620). You say that you called the Plan and was 
told to go to this provider. The Plan denied your request. The Plan says services from non-participating 
providers are not covered under your Plan unless they are authorized by the Plan before the services are 
provided. 
 
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 eyewear is obtained through an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan pays up to $400 every year for non-
Medicare covered prescription eyewear. The Plan rules also say that if you choose to use a provider outside of 
the network, your services will not be covered. Based on this information, we decided that the Plan's rules for 
coverage of frames (V2020), lenses (V2783), variable asphericity lens (V2410), anti-reflective coating (V2750) 
and a routine eye examination (S0620) have not been met. Therefore, we decided that the Plan does not have to 
pay for frames (V2020), lenses (V2783), variable asphericity lens (V2410), anti-reflective coating (V2750) and 
a routine eye examination (S0620) provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adult prophylaxis (D1110) and a periodic oral evaluation 
(D0120) provided on August 2, 2023. 
 You asked the Plan to pay for an adult prophylaxis (D1110) and a periodic oral evaluation (D0120). You say 
that your Plan includes full payment of all costs each calendar year until your annual benefit is exhausted. You 
also say you want this paid immediately. 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. 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 out-of-
network preventive and comprehensive dental services.  
 
You have been asked to pay 20% coinsurance for out-of-network dental services. Adult prophylaxis (D1110) 
and periodic oral evaluations (D0120) fall within the dental 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 pay for an adult prophylaxis (D1110) and a periodic oral evaluation (D0120) provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided on July 
19, 2023. 
 
You asked the Plan to pay for 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 May 16, 2023. Therefore, 
we decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided on July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020) and progressive lenses (V2781) provided on 
Mach 18, 2023. 
 
You asked the Plan to pay for frames (V2020) and progressive lenses (V2781). You say that you would like the 
Plan to transfer the balance to the other Plan for payment. The Plan denied your request. The Plan says this 
benefit has been exhausted. 
 
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 a $100 maximum benefit every two calendar years combined in-network and out-of-
network for eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that eyewear is limited to a $100 maximum 
benefit every two calendar years. The record shows that the benefit was exhausted with this date of service. 
Based on this information, we decided that the Plan's rules for coverage of frames (V2020) and progressive 
lenses (V2781) have not been met. Therefore, we decided that the Plan does not have to pay for frames 
(V2020) and progressive lenses (V2781) provided on Mach 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for an office visit 
 
You asked the Plan to increase the reimbursement for an office visit. You say that you disagree with the 
reimbursement. The Plan denied your request. The Plan says The Plan says you were reimbursed the correct 
amount. 
 
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 0% 
coinsurance for physician/practitioner services, including doctors office visits.  
 
 
 
 You have been asked to pay 0% coinsurance for an office visit. The record shows you should only be 
reimbursed $131.14, which is the maximum allowable amount. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
reimbursed 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 increase the reimbursement for an office visit
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotics provided on September 8, 2022. 
 
You asked the Plan to pay for the orthotics. You say that you were told by your doctor that you did not need a 
referral, but a pre-authorization from the vendor. The Plan denied your request. The Plan says the provider is 
not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the orthotics provided on September 8, 
2022.