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

 
We decided that the Plan does not have to pay for the custom fabricated abutmentincludes placement (D6057) 
and the abutment supported porcelain/ceramic crown (D6058) provided on January 26, 2023. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not 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 items provided are not among those 
covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pay for the custom fabricated abutmentincludes 
placement (D6057) and the abutment supported porcelain/ceramic crown (D6058) provided on January 26, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 19, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from October 1, 2022, 
to October 17, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not aware of the copayment 
amount for the SNF stay. 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 $0 
copayment for days 1 to 20, a $188 copayment each day for days 21 to 40, and $0 copayment for days 41 to 
100 for SNF care.  
 
You have been asked to pay a $1,52.82 copayment for a SNF stay. The copayment applied is less than the 
standard amount for a SNF stay due to the maximum out-of-pocket being met. This item/service falls within 
the SNF 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 a SNF stay provided from 
October 1, 2022, to October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 23, 2023, and January 
26, 2023. 
 
You asked the Plan to pay for dental services. You say that your dentures broke, and you had to get new ones, 
so you feel you should not have to pay for them. The Plan denied your request. The Plan says this service is not 
covered under your 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. Adjunctive pre-diagnostic, 
implant maintenance procedures, when prostheses are removed and reinserted, including cleansing of 
prosthesis & abutments, complete denture  maxillary and unspecified removable prosthodontic procedure - by 
report are not covered under the Plans dental benefits. 
 
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 dental 
services provided on January 23, 2023, and January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 August 15, 2019. 
Therefore, we decided that the Plan does not have to pay for the dental services on January 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established 
patient (D0180) provided on January 18, 2023. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial of payment, and 
you would like your insurance to pay for the billed charges. The Plan denied your request. The Plan says this 
service is not covered under your 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. Comprehensive periodontal 
evaluation - new or established patient (D0180) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0180 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for comprehensive 
periodontal evaluation - new or established patient (D0180) provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays-two radiographic images (D0272) and 
the resin-based composite-one surface, anterior (D2330) provided on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says that you have exhausted the allowable 
benefit for the bitewing x-rays provided in this case. Additionally, the resin-based composite provided 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. 
  
 
The record shows that you have exhausted the allowable benefit for the bitewing x-rays provided in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. Specifically, 
the Plan contract states that one set of bitewing x-rays (up to four views) are covered every 2 years, or up to six 
periapical films every 2 years (not both). You received an intraoral periapical x-ray that was paid for by the 
Plan within the same claim submitted by the provider. Therefore, you have exhausted the allowable benefit for 
this service. Additionally, a resin-based composite is not a covered benefit under your supplemental dental 
policy. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays-two radiographic 
images (D0272) and the resin-based composite-one surface, anterior (D2330) provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0210 and D0150) on December 20, 
2022. 
 
You asked the Plan to pay for the dental services (D0210 and D0150). You say that you would like to request 
reconsideration of the denied claim. 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 November 15, 2022. Therefore, we decided that the Plan does not have to pay for the dental services (D0210 and D0150) on 
December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-two surfaces, posterior for teeth 
number 5 and 13 (D2392), resin-based composite-one surface, posterior for tooth number 28 (D2391), resin-
based composite-three surfaces, anterior for tooth number 24 (D2332), and the resin-based composite-two 
surfaces, anterior for tooth number 25 (D2331 x 2) provided on May 19, 2022 and November 15, 2022. 
 
You asked the Plan to pay for the dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the dental items provided 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 items provided has already been exhausted. Specifically, the Plan contract states that 
resin and amalgam fillings are covered once every 48 months, per tooth. The record shows that you previously 
received a resin-based composite for tooth number 5 on November 9, 2021, a resin-based composite for tooth 
number 28 on April 26, 2021, a resin-based composite for tooth number 13 on October 1, 2020, a resin-based 
composite for tooth number 24 on November 16, 2021, and a resin-based composite for tooth number 25 on  
November 16, 2021. These dental items were provided less than 48 months ago. Therefore, you have exhausted 
the allowable benefit for the items provided in this case. Therefore, we decided that the Plan does not have to 
pay for the resin-based composite-two surfaces, posterior for teeth number 5 and 13 (D2392), resin-based 
composite-one surface, posterior for tooth number 28 (D2391), resin-based composite-three surfaces, anterior 
for tooth number 24 (D2332), and the resin-based composite-two surfaces, anterior for tooth number 25 
(D2331 x 2) provided on May 19, 2022 and November 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each ambulance service provided on 
August 16, 2021, to August 22, 2021. 
 
You asked the Plan to waive the copayment for each ambulance service. You say that theses costs should be 
covered by the Plan. 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 $200 
copayment for in-network one-way ambulance services. 
 
You have been asked to pay a $200 copayment for each ambulance service. This item/service falls within the in-network one-way 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. You have been asked to pay a total of $400 for the ambulance services 
($200 copayment per trip x 2 trips = $400). Therefore, we decided that the Plan does not have to waive the 
copayment for each ambulance service provided on August 16, 2021, to August 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Monitor test (0013M) provided on November 
9, 2022. 
 
You asked the Plan to pay for the Cxbladder Monitor test. You say that this service was medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder Monitor test have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder Monitor test (0013M) provided on November 9, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
March 18, 2022, to March 23, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you met your out-of-
pocket maximum before this date. 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 $285 
copayment per day for days 1-6 of each inpatient hospital stay. Your contract with the Plan also clearly says 
that you then pay a $0 copayment for any additional days of the same inpatient stay. 
 
The records show your out-of-pocket maximum was processed correctly. Due to meeting your out-of-pocket 
maximum, you have only been asked to pay $1,258.52, which is less than the standard $285 copayment per day 
for days 1-5 of the inpatient hospital stay. This item/service falls within the inpatient hospital care benefit 
category. You have not been charged for the day you were discharged. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the inpatient hospital stay provided from March 18, 2022, to March 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Integra bilayer matrix wound dressing provided on October 
04, 2022. 
 
You asked the Plan to pay for Integra bilayer matrix wound dressing. You say that the 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 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 Integra bilayer matrix 
wound dressing provided on October 04, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on January 10, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration because only the 
specimen was sent to process. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
January 10, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from 
November 3, 2022, to January 11, 2023. 
 
You asked the Plan to waive the copayments for the physical therapy visits. You say that you did not know 
there was a $30 copayment per visit. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment per day, for in-network Medicare-covered physical therapy services.  You have been asked to pay a $30 copayment for each physical therapy visit. You have been asked to pay a 
total of $330 ($30 copayment x 11 visits = $330). These items/services fall within the outpatient rehabilitation 
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 copayments for the physical therapy visits 
provided from November 3, 2022, to January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve an SI joint injection. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections (SIJI) will be considered 
medically reasonable and necessary when certain requirements are met.  
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 an SI joint injection. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation on 
physical examination of three (3) or more positive tests results. The clinical value and effectiveness of an SI 
joint injection in the absence of tenderness and negative provocative testing results have not been demonstrated 
in the peer-reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an SI joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
September 30, 2022, to October 8, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
fully covered by the Plan. 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 per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 for each admission to inpatient 
hospital care. 
 
 You have been asked to pay a $350 copayment per day, for days 1 to 5 of the inpatient hospital stay. You have 
been asked to pay a total of $1,750 ($350 copayment x 5 days = $1,750). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient hospital stay provided from September 30, 2022, to 
October 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the dermatology specialist office visit 
provided on November 8, 2022. 
 
You asked the Plan to waive the deductible for the specialist office visit. You say that you had already met your 
deductible. 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 $150 deductible which applies to in-network physician/practitioner 
services. Your contract with the Plan also says that enrollees must pay 4% coinsurance after meeting the 
deductible for in-network specialist office visits. 
 
The record shows your 2022 deductible was processed correctly. You have been asked to pay $81.45 towards 
the deductible. The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner services benefit category. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $150 deductible which applies to in-network physician/practitioner services. This 
cost sharing is a contractual obligation that had not been met at the time the specialist office visit was received 
on November 8, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the 
dermatology specialist office visit provided on November 8, 2022.