Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy visit provided on 
January 25, 2023, to February 13, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy visit. You say that you were told that the 
services would be fully covered. 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 outpatient rehabilitation services. 
 
You have been asked to pay a $25 copayment for each physical therapy visit. This item/service falls 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. The total amount you owe is $50 ($25 copayment x 2 visits = $50). Therefore, 
we decided that the Plan does not have to waive the copayment for each physical therapy visit provided on 
January 25, 2023, to February 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an in-network emergency room (ER) visit, 
and inpatient stay provided from May 10, 2023, to May 14, 2023. 
 
You asked the Plan to waive the copayments for an in-network ER visit and inpatient stay. You say that you 
feel you should not have to pay a copayment for these services, as your treatment was horrible. 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 $95 
emergency services copayment, and a $525 copayment for inpatient hospital services.  
 You have been asked to pay a $620 total copayment for an in-network ER visit and inpatient stay ($95 + $525 
= $620).  
 
This item/service falls within the emergency services and inpatient hospital 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 an in-network emergency room (ER) visit, and inpatient 
stay provided from May 10, 2023, to May 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of gingival inflammation (D4346) 
provided on July 11, 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 July 18, 2022, and 
January 26, 2023. Therefore, we decided that the Plan does not have to pay for scaling in presence of gingival 
inflammation (D4346) provided on July 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive or lower the copayment for an in-network acute inpatient stay 
provided from September 22, 2022, to September 27, 2022. 
 
You asked the Plan to waive or lower the copayment for an in-network acute inpatient stay. You say that you 
were kept in a recovery room for each day except for the last. There was no bathroom in your room, and you 
needed to walk down the hallway to use it.  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 $220 
copayment per day, for days 1-5 for inpatient hospital services.  
 
You were in the hospital for 5 days, resulting in a $1,100 total copayment ($220 x 5 = $1,100). You have been asked to pay a $220 copayment per day, for days 1-5 for an in-network acute inpatient stay. 
This item/service falls within the inpatient hospital 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 or lower the copayment for an in-network acute inpatient stay provided from September 22, 2022, to 
September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on June 22, 2023. 
 
You asked the Plan to pay more for the dental services. You say that these services should be covered. 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 dental services provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health services provided on October 20, 2022. 
 
You asked the Plan to pay for the behavioral health services. You say that you are appealing the denial with 
supporting documentation. 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 the behavioral health 
services provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 26, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating you were 
told by plan representative these were 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 June 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatments with no transports 
provided on June 11, 2023, to June 18, 2023. 
 
You asked the Plan to pay for the ambulance response and treatments with no transports. You say that you feel 
this should be covered under the insurance as you are in a very rural area. You also say that it was a real 
emergency as you fell, had no use of your arms, legs, or feet. The Plan denied your request. The Plan says these 
services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 11, 2023 to June 18, 2023. The ambulance 
benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the 
services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and 
treatments with no transports provided on June 11, 2023, to June 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2331, D2332, and D2335) 
provided on February 3, 2023. 
 
You asked the Plan to pay for resin-based composites. You say that you were told that these services would be 
covered. The Plan denied your request. The Plan says the denied dental services are not covered 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 resin-
based composites (D2331, D2332, and D2335) provided on February 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on April 21, 
2023. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you say that you dont feel you 
should have to pay the copayment for the surgical biopsy because you feel that the doctor hit the wrong area 
with the needle when completing the biopsy which caused you to end up in the ER. 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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $300 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 outpatient surgery provided on 
April 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
June 11, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that the ER provider 
told you an MRI was not necessary, but you had an MRI performed at your primary care a few days later and 
multiple injuries were found. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within the emergency 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 an emergency room 
(ER) visit provided on June 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) for tooth #18, the sedation (D9243), 
and the medicaments (D9630) provided by on June 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel that your claim should fall under 
regular surgery and not dentistry. The Plan denied your request. The Plan says your annual dental maximum 
benefit for the year 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. 
 
The requested extraction, sedation, and medicaments in dispute meets the Medicare definition of dental, since it 
is a service which involved the care and treatment of teeth or structures directly supporting the teeth. The 
extraction, sedation, and medicaments does not fall under any of Medicare exceptions for coverage of non-
routine dental care. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations 
apply. The record shows the Plan paid $113 for dental services on June 6, 2023. On June 20, 2023, the Plan 
paid $387 for dental services. For the year of 2023 the Plan paid $500 ($113 paid + $387 paid) for dental 
services; therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the date of 
service of June 20, 2023. Therefore, we decided that the Plan does not have to pay for an extraction (D7210) 
for tooth #18, the sedation (D9243), and the medicaments (D9630) provided by on June 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the requested LDCT scan is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the Medicare criteria was not 
met. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that that the enrollee is not between the age of 50-77 
years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography 
(LDCT) scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 31, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service was 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 May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on June 27, 2023. 
 
You asked the Plan to pay for the dental service. You say that you went to a new dentist and the x-rays taken 
were needed to get a baseline. 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 the date of service of June 29, 2021. 
Therefore, we decided that the Plan does not have to pay for the intraoral complete series of radiographic 
images (D0210) provided on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a comprehensive oral 
evaluation (D0150), the intraoral radiographic images (D0220 and D0230), a panoramic radiographic image 
(D0330), a complete upper denture (D5110), a complete lower denture (D5120), an extraction (D7140) for 
tooth #4, #5, #6, #7, #8, #9, #10, #11, and #12, and a palliative treatment of dental pain (D9110) provided by 
an out-of-network provider on August 25, 2022, September 12, 2022, September 14, 2022, October 12, 2022, 
and February 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider never told you anything about not 
accepting your insurance. 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. Also, it was verified that you 
were referred to an in-network provider by the 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. 
 
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 limited oral evaluation (D0140), a comprehensive oral evaluation (D0150), the intraoral 
radiographic images (D0220 and D0230), a panoramic radiographic image (D0330), a complete upper denture 
(D5110), a complete lower denture (D5120), an extraction (D7140) for tooth #4, #5, #6, #7, #8, #9, #10, #11, 
and #12, and a palliative treatment of dental pain (D9110) provided by an out-of-network provider on August 
25, 2022, September 12, 2022, September 14, 2022, October 12, 2022, and February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic x-ray (D0330) provided on September 2, 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 January 19, 2022. 
Therefore, we decided that the Plan does not have to pay for panoramic x-ray (D0330) provided on September 
2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the replace broken teeth - per tooth (D5640) service 
provided on July 26, 2022. 
 
You asked the Plan to pay more for the dental service. 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. Enrollees must pay 50% 
coinsurance for service D5640 and may be billed by the out-of-network provider for any amount greater than 
the payment made by the plan to the provider. 
 For service D5640 the provider billed $225.25, and the allowed amount is $84.00. You are responsible for a 
50% coinsurance for this service of $42.00 ($84.00 x 50%). The plan issued the remaining allowed amount of 
$42.00 ($84.00 x 50%). You are also responsible for any cost over the allowed amount $141.25 ($225.25 - 
$84.00). Your liability of $183.25 ($141.25 + $42.00) is correct. 
 
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 dental service have not been met. Therefore, we decided that the Plan does 
not have to pay more for the replace broken teeth - per tooth (D5640) service provided on July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, methadone provided on May 
22, 2023. 
 
You asked the Plan to pay for medication assisted treatment, methadone. 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 medication assisted 
treatment, methadone provided on May 22, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 
21, 2023. 
 
You asked the Plan to pay for the ED services. You say that you have provided the medical documentation and 
would like the claim reprocessed. The Plan denied your request. The Plan says Medicare payment cannot be 
made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 21, 2023.