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

 
We decided that the Plan does not have to reduce the coinsurance for Medicare Part B injections provided from 
January 26, 2023, to March 29, 2023. 
 
You asked the Plan to reduce the coinsurance for Medicare Part B injections. You say that you are unsure what 
changed but your copayment used to be $36 per month and you are unable to afford the new cost share. 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 Medicare Part B drugs.  
 
 You have been asked to pay a total coinsurance of $1,418.22 for Medicare Part B injections. This total includes 
$472.74 for each injection, which is 20% of the allowed amount ($2,363.70 allowed x 20% = $472.74 per 
injection x 3 injections = $1,418.22). This item/service falls within the Medicare Part B 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 reduce the coinsurance for Medicare Part B injections provided from January 26, 
2023, to March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the panoramic x-ray (D0330) provided on November 3, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you were never notified that the x-rays would 
not be covered or that it would be an additional cost. The Plan denied your request. The Plan says that these x-
rays are above the Plan limit and are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. The rules say that Medicare health plans must make reasonable and diligent 
efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 
Medicare rules also say that Medicare health plans must disclose to its enrollees, in clear accurate terms, any 
applicable conditions and limitations associated with use of benefits.  
 
You were referred for the panoramic x-ray by a contract provider. The file does not show that the Plan 
provided notice that the panoramic x-ray would not be covered. Under Medicare rules, this means the 
panoramic x-ray is considered approved by the Plan. The Plans 2022 EOC states that panoramic film may be 
taken in place of Intraoral  complete series (D0210). However, this language is not clear that there is a 
limitation which only allows coverage for either panoramic film or an intraoral - complete series. Because 
panoramic film could be covered under some conditions, the EOC alone is not adequate notice of non-
coverage. You reasonably believed that by going to a participating dentist, they would only provide x-rays that 
would be covered by the Plan. The Plan has not provided any documentation to show that they had paid for any 
other panoramic film (D0330) within the previous 12 months of the date of service in dispute. The Plan has not 
substantiated their denial reason that the benefit for panoramic film was exhausted.  Therefore, we decided that 
the Plan has to pay for the panoramic x-ray (D0330) provided on November 3, 2022.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on March 
26, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that you did have one in the last 36 
months, but the x-rays were unreadable due to the poor service you received at your old dentist. You also say 
that you would like coverage for these x-rays to be reconsidered. The Plan denied your request. The Plan says 
your benefit for the panoramic radiographic image 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 panoramic radiographic image was exhausted on date of service April 19, 2022. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on March 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a hearing aid (V529) purchased on September 7, 2021. 
 
You asked the Plan to reimburse for a hearing aid (V529). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says a request for reimbursement must be made within 365 
days of the date of service in order for payment to be considered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for a hearing aid (V529) was not filed until February 13, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to reimburse for a hearing aid (V529) purchased on September 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the eye injections provided from January 
20, 2023, to February 17, 2023. 
 
You asked the Plan to waive the copayments for the eye injections. You say that you believe you were double 
billed. You say you should not have to pay for an outpatient copayment when the services can be done in an 
office for less money. 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 $295 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
 You have been asked to pay a $295 copayment for the eye injections on each date of service. The eye injections 
fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. The record shows the services were billed with the place of service code, 22, 
which is for an outpatient hospital. 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 eye injections 
provided from January 20, 2023, to February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network skin lesion removal provided 
on March 7, 2023. 
 
You asked the Plan to waive the deductible for an in-network skin lesion removal. You say that you are 
supposed to only have an $18 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. Your 
contract with the Plan says that there is a $233 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
You have bee asked to pay $226.13 towards this $233 deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctors office visits benefit category.  The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $233 deductible which 
applies to physician/practitioner services, including doctors office visits. This cost sharing is a contractual 
obligation that had not been met at the time an in-network skin lesion removal was received on March 7, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for an in-network skin lesion 
removal provided on March 7, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy (97802) provided on November 
8, 2022. 
 
You asked the Plan to pay for the medical nutrition therapy services. The Plan denied your request. The Plan 
says medical nutrition therapy (MNT) is covered by Medicare only for diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
 Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy (97802) provided on November 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a compression device and the accessories to be provided 
by an OON provider.  
 
You asked the Plan to pre-approve a compression device and the accessories. You say that you are requesting 
reconsideration of the denied items. The Plan denied your request. The Plan says this service was not approved. 
 
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 
a compression device and the accessories to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network office visit provided on 
March 14, 2023. 
 
You asked the Plan to waive the deductible for an in-network office visit. You say that this was a simple office 
visit and should not have this high of a 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. Your 
contract with the Plan says that there is a $675 deductible which applies to outpatient hospital services. You 
have been asked to pay $110.72 towards this deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient hospital services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $675 
deductible which applies to outpatient hospital services. This cost sharing is a contractual obligation that had 
not been met at the time an in-network office visit was received on March 14, 2023. Therefore, we decided that 
the Plan does not have to waive the deductible for an in-network office visit provided on March 14, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a physical therapy (PT) evaluation 
provided on March 07, 2023. 
 
You asked the Plan to waive the copayment for a physical therapy (PT) evaluation. You say that you did not 
receive therapy services and was only taken to look at a scooter. 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 outpatient rehabilitation services. 
 
You have been asked to pay a $35 copayment for a physical therapy (PT) evaluation. 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. Therefore, we decided that the Plan does not have to waive the copayment 
for a physical therapy (PT) evaluation provided on March 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a partial lower denture (D5741) provided on 
April 26, 2023. 
 
You asked the Plan to pay for the dental service. You say that you did not realize that there was a timeframe of 
every 36 months and the dentist needed to correct it. 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 December 16, 
2021. Therefore, we decided that the Plan does not have to pay for the reline of a partial lower denture (D5741) 
provided on April 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an MRI and radiation therapy provided on 
October 21, 2022. 
 
You asked the Plan to waive the cost share for an MRI and radiation therapy. You say that you are unable to 
afford the cost share. 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 $100 
copayment when advanced imaging services are provided in an outpatient hospital facility and 20% 
coinsurance for radiation therapy.  
 
 
You have been asked to pay $2,081.09 for an MRI and radiation therapy. This total includes a $100 copayment 
for an MRI and $1,981.09 coinsurance, which is less than the standard amount for radiation therapy due to your 
maximum out-of-pocket being met with the processing of this claim. These items/services fall within the 
outpatient diagnostic tests 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 share for an MRI and 
radiation therapy provided on October 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on April 14, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you should 
have been educated on the cost share instead of being surprised by a bill. 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 $170 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $170 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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 you owe is $121.75, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on April 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B injection provided on 
February 07, 2023. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B injection. You say that you were unaware 
there would be such a large cost share for the appointment. 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 Medicare Part B Prescription Drugs. 
 
You have been asked to pay 20% coinsurance for a Medicare Part B injection. This item/service falls within the 
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. The total you owe is $418.19, which is 20% of the allowed amount for a 
Medicare Part B drug injection ($2,090.97 allowed x 20% = $418.19). Therefore, we decided that the Plan does 
not have to waive the coinsurance for a Medicare Part B injection provided on February 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) 
provided on April 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam CT capture and interpretation (D0364) provided on April 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 3, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport provided on November 
3, 2022. You say that the security personnel from where your father lived called for the ambulance. You also 
say that you or your father did not request this service or use it.  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 November 3, 2022. 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 treatment with no 
transport provided on November 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each physical therapy (PT) visit provided 
on March 22, 2023, to March 29, 2023. 
 
You asked the Plan to reduce the copayment for each physical therapy (PT) visit. You say that you would like 
the copayment to be reduced to $35. 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 outpatient rehabilitation services. 
 
You have been asked to pay a $35 copayment for each physical therapy (PT) 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 you owe is $70 for PT services ($35 per visit x 2 visits = $70). 
Therefore, we decided that the Plan does not have to reduce the copayment for each physical therapy (PT) visit 
provided on March 22, 2023, to March 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on February 17, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. 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 home visit provided on 
February 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the thorax andlLow osmolar 
contrast material provided on March 09, 2023. 
 
You asked the Plan to pay for computed tomography (CT) of the thorax andlLow osmolar contrast material. 
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 computed tomography 
(CT) of the thorax andlLow osmolar contrast material provided on March 09, 2023.