Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the nebulizer provided on December 12, 
2022. 
 
You asked the Plan to waive the deductible for the nebulizer. You say that the Plan should have paid for this. 
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 $750 deductible which applies to out-of-network durable medical 
equipment and related supplies. Your contract with the Plan also says that you must pay 20% coinsurance after 
meeting the deductible for out-of-network durable medical equipment and related supplies. 
 
 The item or service you asked the Plan to waive the deductible for falls within the out-of-network durable 
medical equipment and related supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to out-of-network durable medical 
equipment and related supplies. This cost sharing is a contractual obligation that had not been met at the time 
the nebulizer was received on December 12, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for the nebulizer provided on December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze provided on November 14, 2022. 
 
You asked the Plan to pay for gauze. You say that this service is supported in the records. 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 gauze provided on 
November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care office visit provided on 
December 12, 2022. 
 
You asked the Plan to waive the copayment for the primary care office visit. You say that you feel that the Plan 
should pay for this. 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 $10 
copayment for primary care physician/practitioner services. 
 
You have been asked to pay a $10 copayment for the primary care office visit. This item/service falls within 
the primary care physician/practitioner 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 records show the Plan reprocessed this claim, applying the 
$10 primary care provider office visit copayment instead of the $15 specialist office visit copayment. 
Therefore, we decided that the Plan does not have to waive the copayment for the primary care office visit 
provided on December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided 
on December 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not agree with the denial of payment. 
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. This benefit includes the 
requested D0140 but is limited to one procedure per plan year. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D0140 on August 11, 2022. Therefore, this benefit was exhausted as of December 
8, 2022. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused 
(D0140) provided on December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond of an inlay, onlay, veneer or partial 
coverage restoration (D2910) provided on December 29, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-cement or  
re-bond of an inlay, onlay, veneer or partial coverage restoration (D2910) provided on December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planning (D4342 x 4) 
provided from October 11, 2022, to October 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that after a deep cleaning you got an infection, and 
this procedure needed to be corrected to save your teeth. 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 dates of service September 7, 2021, 
September 22, 2021, and September 24, 2021. Therefore, we decided that the Plan does not have to pay for the 
periodontal scaling and root planning (D4342 x 4) provided from October 11, 2022, to October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on January 25, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the enrollee's dentist sent them to a surgeon to 
get a tooth extracted and you would like the claim to be paid. 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 the Plan paid for a limited oral evaluation (D0140) on January 4, 2023, and paid for a comprehensive 
oral evaluation (D0150) on January 5, 2023; therefore, the enrollees benefit for the requested item or service 
was exhausted on the date of service of January 5, 2023. Therefore, we decided that the Plan does not have to 
pay for a limited oral evaluation (D0140) provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjunctive prediagnostic (D0431), localized delivery of 
agents into tissue (D4381), scaling root planing (D4342), gingival irrigation (D4921) and other drugs (D9630) 
provided on January 24, 2023. 
 
You asked the Plan to pay for adjunctive prediagnostic, localized delivery of agents into tissue, scaling root 
planing, gingival irrigation, and other drugs. You say that this should be covered. The Plan denied your request. 
The Plan says these are not covered services. 
 
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 
adjunctive prediagnostic (D0431), localized delivery of agents into tissue (D4381), scaling root planing 
(D4342), gingival irrigation (D4921) and other drugs (D9630) provided on January 24, 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 October 10, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
not conscious of your state of health after receiving the shocking, sudden death news of your brother. You also 
say that you blacked-out and awoke to paramedics at your side. 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 October 10, 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 October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-cement or re-bond crown (D2920) provided January 18, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you had no way to know there was a 24-month 
limitation. 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. This benefit includes the 
requested re-cement or re-bond crown (D2920) but is limited to one procedure per 24 floating months 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered re-cement or re-bond crown (D2920) on May 5, 2021. Therefore, this benefit has 
been exhausted as of January 18, 2023. Therefore, we decided that the Plan does not have to pay for re-cement 
or re-bond crown (D2920) provided January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 31, 2022. 
 
You asked the Plan to pay for the office visit. You say that you were not aware that the services were not 
authorized. 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 office visit provided 
on May 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of lower extremity arteries provided on 
December 05, 2022. 
 
You asked the Plan to pay for duplex scan of lower extremity arteries. You say that the services should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for duplex scan of lower 
extremity arteries provided on December 05, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a trabeculoplasty by laser surgery 
procedure provided on January 27, 2023. 
 
You asked the Plan to waive the copayment for a trabeculoplasty by laser surgery procedure. You say that you 
had this procedure done 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 $150 
copayment for in-network Medicare-covered ambulatory surgical services. 
 
You have been asked to pay a $150 copayment for a trabeculoplasty by laser surgery procedure. This 
item/service falls within the in-network Medicare-covered ambulatory surgical 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 trabeculoplasty by laser surgery procedure provided on 
January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on January 10, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that this service is supported in the 
records. 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 and 
related services provided on January 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Minuteman procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the minuteman procedure is experimental. 
 
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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 21, 2023, to January 25, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should have been 
discharged sooner resulting in a lower 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 $295 
copayment per day for days 1-6 of each inpatient hospital stay. Your contract with the Plan also clearly says that you then pay a $0 copayment per day for days 7-90 of the same inpatient stay. 
 
You have been asked to pay a $295 copayment per day for days 1-4 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged for the day you 
were discharged. You have been asked to pay a total of $1,180 ($295 copayment per day x 4 days = $1,180). 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the inpatient hospital stay provided from January 21, 2023, 
to January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on January 16, 2023. 
 
You asked the Plan to pay for a new patient office visit. You say that you were referred to this provider by your 
primary care provider (PCP). 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 new patient office visit 
provided on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care office visit provided on 
January 02, 2023. 
 
You asked the Plan to waive the copayment for the urgent care office visit. You say that you were not able to 
see your primary care provider on this date. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for urgently needed services. 
 
You have been asked to pay a $35 copayment for the urgent care office visit. This item/service falls within the 
urgently needed 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 urgent 
care office visit provided on January 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) 
provided on December 20, 2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service August 16, 2022.  
  
 
Specifically, the Plan provides coverage for one limited oral evaluation every year. You previously received 
this service on August 16, 2022, which was paid for by the Plan. Therefore, you have exhausted the allowable 
benefit for this service. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation-
problem focused (D0140) provided on December 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on August 
09, 2022. 
 
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 $245 
copayment for outpatient surgery/Medicarecovered ambulatory surgical center visit.. 
 
You have been asked to pay a $245 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/Medicarecovered ambulatory surgical center visit. 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 August 09, 2022.