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

 
We decided that the Plan does not have to waive the copayments for the breast ultrasound and x-ray provided 
from January 28, 2023, to February 27, 2023. 
 
You asked the Plan to waive the copayments for the breast ultrasound and x-ray. You say that this was for a 
mammogram, which 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 $60 
copayment for each diagnostic ultrasound. Your contract with the Plan also clearly says that you must pay a 
$30 copayment for each x-ray service. 
 The records show a complete breast ultrasound was provided, and the copayment was applied correctly. You 
have been asked to pay a $60 copayment for the breast ultrasound. You have also been asked to pay a $30 
copayment for the x-ray service. These items/services fall within the outpatient diagnostic tests and therapeutic 
services benefit category. You have been asked to pay a total of $90 ($60 copayment + $30 copayment = $90). 
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 breast ultrasound and x-ray provided from January 28, 
2023, to February 27, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on  
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $270 
copayment for outpatient surgery/outpatient procedures and services.  
 
You have been asked to pay a $270 copayment for an outpatient surgery. However, you are only being asked to 
pay $190 which is less than the required amount. This item/service falls within the outpatient 
surgery/outpatient procedures and 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 an outpatient surgery provided on
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic testing provided on November 07, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for diagnostic testing. You say that this is in network. The Plan denied your request. 
The Plan says the enrollee must receive their care from a network provider (for more information about this, 
see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network provider (a 
provider who is not part of the plans network) will not be 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 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 diagnostic testing provided on November 07, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 30, 2022 to December 
23, 2022, by an out-of-network (OON) provider.  
 
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 this was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on November 30, 2022 to 
December 23, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each home infusion therapy administration 
provided on May 06, 2021, to August 30, 2021. 
 
You asked the Plan to reduce the copayment for each home infusion therapy administration. You say that you 
were paying only $15 a month for this service. 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 home infusion therapy. 
 
You have been asked to pay a $35 copayment for each home infusion therapy administration. This item/service 
falls within the home infusion therapy 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 $595 ($35 copayment x 17 visits = $595). 
Therefore, we decided that the Plan does not have to reduce the copayment for each home infusion therapy 
administration provided on May 06, 2021, to August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic pulpotomy (D3220) provided on December 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 the services denied correctly as they do not fall 
within your dental 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 a 
therapeutic pulpotomy (D3220) provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation and cleaning and 
inspection of removable complete maxillary/mandibular denture (D0180, D9932, D9935). 
 
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 the services denied correctly as they do not fall 
within your dental 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 a 
comprehensive periodontal evaluation and cleaning and inspection of removable complete 
maxillary/mandibular denture (D0180, D9932, D9935).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - one surface, posterior (D2391), 
endodontic therapy, premolar tooth (excluding final restoration) (D3320), and intraoral - periapical first 
radiographic image (D0220) provided on January 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are asking the amount to be covered as you 
say this was an emergency and not a planned trip. The Plan denied your request. The Plan says your benefit for 
the requested services $1,000 dollar limit was met. 
 
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 5, 2023. The 
charges were $1,341.00 and the Plan paid the $1,000.00. Since you used a preferred provider, a pre-negotiated 
rate was applied to the claim which lowers what you owe out-of-pocket ($341 - $272 = $69). Therefore, we 
decided that the Plan does not have to pay for a resin-based composite - one surface, posterior (D2391), 
endodontic therapy, premolar tooth (excluding final restoration) (D3320), and intraoral - periapical first 
radiographic image (D0220) provided on January 5, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visits provided on November 
03, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care visits. 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 subsequent nursing 
facility care visits provided on November 03, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on  
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment per day for days -1-5 for inpatient hospital care.  
 
You have been asked to pay a $225 copayment per day for days -1-5 for inpatient hospital care. The total 
amount you are being asked to pay is $675 ($225 x 3 days = $675). 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 inpatient hospital care 
provided on
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast biopsy, and the diagnostic 
mammogram provided by an in-network provider on January 17, 2023. 
 
You asked the Plan to waive the copayment for the biopsy and the mammogram. You say that you received 
these services before and did not have a copayment. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
copayment for each in-network Medicare-covered outpatient hospital facility visit, and a $35 copayment per 
day, per provider, for in-network Medicare-covered x-ray services. 
 
You have been asked to pay a $290 copayment for the biopsy. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. You have also been asked to pay a $35 copayment for the mammogram. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the breast biopsy, and the diagnostic mammogram provided by an in-
network provider on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic pontic for tooth number 5 (D6245). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 has been exhausted. Specifically, the Plans contract states that up to 
four units of fixed dentures are covered per year.  
  
 
The Plan previously authorized retainer crowns for teeth number 2, 4, and 6 and a pontic for tooth number 3.  
Therefore, you have exhausted the allowable benefit for the requested dental item. Therefore, we decided that 
the Plan does not have to pre-approve a porcelain/ceramic pontic for tooth number 5 (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - mandibular (D5120), and surgical 
placement of implant body: endosteal implant (D6010) provided on May 2, 2022, and August 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you chose this dentist since they were close to 
your home. 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.  
 
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 complete denture - mandibular (D5120), and 
surgical placement of implant body: endosteal implant (D6010) provided on May 2, 2022, and August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5130 x 2), dispensing fee 
(V5160), sales tax (S9999), and the conformity evaluation (V5020) purchased on November 22, 2022. 
 
You asked the Plan to issue reimbursement for these 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 payable as 
they were not purchased from the Plans select hearing aid provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids/services only when purchased through the Plans select hearing aid provider.  
 
 We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract says that hearing aids/services are 
covered only when purchased through the Plans select hearing aid provider. However, the hearing 
aids/services in this case were not purchased through the Plans select hearing aid provider. Therefore, we 
decided that the Plan does not have to issue reimbursement for the hearing aids (V5130 x 2), dispensing fee 
(V5160), sales tax (S9999), and the conformity evaluation (V5020) purchased on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections on October 25, 2022.  
 
You asked the Plan to waive the coinsurance for injections. 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 20% 
coinsurance for all drugs covered under Original Medicare. These drugs are covered under Part B of Original 
Medicare. Members of the plan receive coverage for these drugs through our plan. Covered drugs include drugs 
that usually arent self-administered by the patient and are injected or infused while you are getting physician, 
hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of $4,900 and the 
allowed amount is $2,955. $2,955.88 x 20% = $591.18. Therefore, results in the total cost sharing amount of 
$591.18. You have been asked to pay a 20% coinsurance for injections. 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. Therefore, we decided that the Plan does not have to waive the coinsurance for injections on 
October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and extraction (D0140, D7140) 
provided on January 3, 2023, to February 9, 2023. 
 
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 the services denied correctly as they do not fall 
within your dental 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 a limited 
oral evaluation and extraction (D0140, D7140) provided on January 3, 2023, to February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on December 30, 2022. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
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 a home visit provided on 
December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 05, 2022. 
 
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 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pain management office visit provided on January 17, 
2023. 
 
You asked the Plan to pay for a pain management office visit. You say that the service happened before the 
auth came in. This was medically necessary and 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 a pain management 
office visit provided on January 17, 2023.