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

 
We decided that the Plan does not have to waive the cost share for the drug injection and specialist office visit 
provided on November 8, 2022. 
 
You asked the Plan to waive the cost share for the drug injection and clinic visit. You say that your out-of-
pocket maximum had been met. 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 Medicare Part B drugs. Your contract with the Plan also clearly says that you must 
pay a $35 copayment for in-network specialist office visits. 
 
The records show your out-of-pocket maximum had not been met and these services were charged correctly. 
You have been asked to pay $1,604.64, which is 20% coinsurance of the allowed amount for the drug injection 
($8,023.18 allowed amount x 20% coinsurance = $1,604.64). This item/service falls within the Medicare Part B 
drugs benefit category. You have also been asked to pay $34.66, which is less than the standard $35 copayment 
for the specialist office visit. This item/service falls within the physician/practitioner services benefit category. 
You have been asked to pay a total of $1,639.30 ($1,604.64 coinsurance + $34.66 copayment = $1,639.30). 
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 drug injection and specialist office visit provided on 
November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry services provided on 
September 01, 2022. 
 
You asked the Plan to waive the copayment for the podiatry services. You say that this service should be fully 
covered under routine care. 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 podiatry services.  
You have been asked to pay a $35 copayment for the podiatry services. This item/service falls within the 
podiatry 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 the podiatry services 
provided on September 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation with limited field 
of view  less than one whole jaw (D0364) and consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on October 3, 2022. 
 
You asked the Plan to pay for dental services. You say that you think the services should be covered under your 
insurance. The Plan denied your request. The Plan says these services are 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. Cone beam CT capture and 
interpretation with limited field of view  less than one whole jaw (D0364) and consultation - diagnostic 
service provided by dentist or physician other than requesting dentist or physician (D9310) are not covered 
under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0364 and D9310 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone 
beam CT capture and interpretation with limited field of view  less than one whole jaw (D0364) and 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided on October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on November 28, 
2022. 
 
You asked the Plan to pay for skilled nursing facility services. You say that you were not able to verify 
eligibility and obtain 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 skilled nursing facility 
services provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain fused to high noble metal (D2750), and 
core buildup, including any pins when required (D2950) provided on November 16, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D2750 and D2950. You say that you do 
not agree with the services not being covered. 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. 
Additionally, D2750 and D2950 are not listed as a covered services even if they were performed by a 
contracted dental 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 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 a crown - porcelain fused to high noble metal (D2750), and core buildup, including any pins when 
required (D2950) provided on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 26, 2023. 
 
You asked the Plan to pay for office visit. You say that you are requesting the submitted documentation 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 office visit provided on 
January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on April 15, 2022. 
 
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 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 October 22, 2020. 
Therefore, we decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on April 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation for teeth number 20, 21 
(D0150) to be rendered by an Endodontist. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. The Plan contract states that the requested service must be performed by a 
participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive 
oral evaluation for teeth number 20, 21 (D0150) to be rendered by an Endodontist.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation services provided on July 11, 2022. 
 You asked the Plan to pay for ambulance transportation. You say that the services rendered were not hospice 
related and are requesting a review of the denied claim. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance transportation services provided on July 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on January 19, 2023, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home visit. You say that authorization is not required for this service. The 
Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 home visit provided on January 19, 2023, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to predominantly base 
metal tooth #'s 7, 9, and 10 (D6751), and pontic - porcelain fused to predominantly base metal tooth #8 
(D6241). 
 
You asked the Plan to pre-approve the retainer crown - porcelain and pontic - porcelain. You say that you are 
requesting an appeal for the denied services. The Plan denied your request. The Plan says the documentation 
did not meet the clinical criteria for the dental services requested. 
 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 Plan covers the retainer 
crown - porcelain and pontic - porcelain when the services are medically necessary and reasonable.  
 
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 the retainer crown - porcelain and 
pontic - porcelain. Our reviewer says that given the current status of the teeth, the bridge would not be 
considered medically necessary. Our physician reviewer found in this instance, it is noted there are missing 
posterior teeth, some of which were replaced with fixed bridgework. The anterior teeth are also endodontically 
involved (9 and 10) and broken down with minimal remaining structure. Tooth #7 appears to have moderate to 
severe periodontal disease. Double abutments are not allowed under the plan, which would be part of the 
requested bridge. Given the Plan criteria, there would be no finding of necessity for the requested procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the retainer crown - porcelain and pontic - porcelain have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to 
predominantly base metal tooth #'s 7, 9, and 10 (D6751), and pontic - porcelain fused to predominantly base 
metal tooth #8 (D6241).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on February 16, 2022, to 
December 13, 2022. 
 
You asked the Plan to pay for outpatient mental health. You say that you say that your PCPs office submitted 
the referral multiple times and the plan should provide the correct information for providers to send referrals. 
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 outpatient mental health 
provided on February 16, 2022, to December 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound care provided on June 08, 2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that you have not had a cost share for 
this before. 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 $175 
copayment for outpatient surgery or procedures at an ambulatory surgical center. 
 
You have been asked to pay a $175 copayment for the wound care. This item/service falls within the outpatient 
surgery or procedures at an ambulatory surgical center 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 has corrected the claim to apply the correct copayment amount. Therefore, we decided that the Plan does not have to waive the copayment for the wound 
care provided on June 08, 2022.
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 records attached support the services provided. 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 31, 2022. 
 
You asked the Plan to pay for an office visit. You say that these services are 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 an office visit provided 
on October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), and 
electronic connection (E2311). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the equipment order was on a sever 
back order. You say that by the time the equipment came in, the authorization was expired. You say that the 
enrollee's health has severely declined, and this wheelchair is necessary to extend their life. The Plan denied 
your request. The Plan says there is no medical need to control the power options through a joystick. 
 
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 the upgraded electronics. Our reviewer 
says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the documentation does not support that it is medically necessary to control the 
requested power options through the joystick (drive interface). The enrollee's left upper extremity strength is 
sufficient to control any power options through their own switches. Therefore, the reviewer found that the 
requested upgraded electronics 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377), harness (E2313), and electronic connection 
(E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve back injections to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the injections. You say that you were in an auto accident and need the 
injections. The Plan denied your request. The Plan says network providers are available to render necessary 
care. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
back injections to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on November 02, 2022, to 
November 09, 2022. 
 
You asked the Plan to waive the copayment for office visit. 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 $30 
copayment for each Medicare-covered specialist visit (including surgery second opinion, telehealth services, 
home infusion professional services, and urgently needed services). Covered services include medically 
necessary medical care or surgery services furnished in a physicians office, certified ambulatory surgical 
center, hospital outpatient department, or any other location and consultation, diagnosis, and treatment by a 
specialist. There were two visits. 2 x $30 = $60. Therefore, results in the total cost sharing amount of $60. 
 
You have been asked to pay a $30 copayment for each office visit. This item/service falls within the 
physician/practitioner services, including doctor's 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 office visit on November 02, 2022, to November 09, 2022.