Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the scaling in presence of generalized moderate or 
severe gingival inflammation  full mouth, after oral evaluation (D4346) provided on June 8, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting reconsideration and 
have submitted the notice of denial of payment, code with narrative, clinical notes, periodontal charts and x-
rays from the provider. The Plan denied your request. The Plan says your benefit for the requested service 
$1,500 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 the Plan paid on claims ending in 328153 for date of service 06/05/2023 in the amount of 
$106.00, claim 819240 for date of service 06/05/2023 in the amount of $168.00, claim 300028 for date of 
service 06/29/2023 in the amount of $698.00, claim 774203 for date of service 07/12/2023 in the amount of 
$418.00, and claim 359127 for date of service 07/06/2023 in the amount of $110.00 ($106 + $168 + $698 + 
$418 + $110 = $1,500. After the annual maximum is exhausted, any remaining charges are your responsibility. 
Since your annual maximum has been satisfied by these claims, no additional payment will be made towards 
scaling in presence of generalized gingival inflammation (D4346). Therefore, we decided that the Plan does not 
have to pay more for the scaling in presence of generalized moderate or severe gingival inflammation  full 
mouth, after oral evaluation (D4346) provided on June 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an in-network bladder procedure provided 
on May 25, 2023, to June 29, 2023. 
 
You asked the Plan to reduce the copayment for an in-network bladder procedure. You say that you have this 
done monthly for the past year and it was $100. You feel $232.40 per month is too much. 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 $350 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $350 copayment for an in-network bladder procedure. This item/service falls 
within the outpatient surgery and other medical 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. However, since the allowed amount is less than the standard copayment, you only owe 
$232.40 per procedure. The total you owe is $465 ($232.40 copayment x 2 visits = $464.80). Therefore, we 
decided that the Plan does not have to reduce the copayment for an in-network bladder procedure provided on 
May 25, 2023, to June 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the opioid treatment program services 
provided on April 01, 2023, to April 29, 2023. 
 
You asked the Plan to waive the copayment for the opioid treatment program services. 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 $55 
copayment for opioid treatment program services. 
 
You have been asked to pay a $55 copayment for the opioid treatment program services. This item/service falls 
within the opioid treatment program 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 $220 ($55 copayment x 4 visits = $220). Therefore, we 
decided that the Plan does not have to waive the copayment for the opioid treatment program services provided 
on April 01, 2023, to April 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a cleaning and periodic oral evaluation (D0120, 
D1110) provided on July 3, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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 a cleaning and periodic oral evaluation 
(D0120, D1110) provided on July 3, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear stress test provided on July 13, 
2023. 
 
You asked the Plan to waive the copayment for the nuclear stress test. You say that you are getting charged for 
services you didnt have. 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 for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $220 copayment for the nuclear stress test. 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. However, since the allowed amount is less than the 
standard copayment, you only owe $156.88. Therefore, we decided that the Plan does not have to waive the 
copayment for the nuclear stress test provided on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), and 
comprehensive oral evaluation - new or established patient (D0150) provided on August 15, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image and comprehensive oral evaluation. You say 
that this was a routine cleaning and x-rays. The Plan denied your request. The Plan says your benefit for the 
requested panoramic radiographic image and comprehensive oral evaluation  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 services was exhausted on date of service August 18, 2021.  Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330), and 
comprehensive oral evaluation - new or established patient (D0150) provided on August 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone morphogenic protein -2 (BMP-2) Allograft and 
Mastergraft Allograft with an elective T7-L2 revision posterior instrumented fusion procedure. 
 
You asked the Plan to pre-approve the BMP-2 Allograft and Mastergraft Allograft with an elective T7-L2 
revision posterior instrumented fusion procedure. You say that if there were to be a shift in the enrollee's 
health, it could cause the enrollee to become paralyzed. The Plan denied your request. The Plan says the 
procedure is not medically necessary. The Plan says the procedure is considered investigational. 
 
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 BMP-2 Allograft and Mastergraft 
Allograft with an elective T7-L2 revision posterior instrumented fusion procedure. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found BMP allograft is not FDA approved for use in the posterior spine. Iliac crest autograft is the gold 
standard. 
 
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 BMP-2 Allograft and Mastergraft Allograft with an elective T7-L2 revision 
posterior instrumented fusion procedure have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the bone morphogenic protein -2 (BMP-2) Allograft and Mastergraft Allograft with an elective 
T7-L2 revision posterior instrumented fusion procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the pulmonary diagnostic testing and 
therapies provided on July 07, 2023. 
 
You asked the Plan to waive the copayment for the pulmonary diagnostic testing and therapies. You say that 
you think it should be $45 because thats what you paid in the past. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for the pulmonary diagnostic testing and therapies. 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. However, since the 
allowed amount is less than the standard copayment, you only owe $70.20. Therefore, we decided that the Plan 
does not have to waive the copayment for the pulmonary diagnostic testing and therapies provided on July 07, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiography (93306) provided on June 
17, 2022, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the transthoracic echocardiography. You say that you would like this claim to be 
reprocessed and payment to be issued to the provider. The Plan denied your request. The Plan says a valid 
authorization was not found on file for the service in question. The Pan also says that no contacts to the Health 
Plan were found regarding the enrollees plan benefit and/or provider participation status for the services prior 
to services being rendered.  
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the transthoracic echocardiography (93306) 
provided on June 17, 2022, by an out-of-network (OON) provider.
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 July 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your benefit for limited oral evaluations has 
already been exhausted. Additionally, the cost-sharing applied to the extractions is correct. 
 
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 limited oral evaluations was exhausted on date of service July 7, 2023, and July 12, 
2023 (D0140). 
 
You have been asked to pay a 20% coinsurance for an extraction. This item/service falls within the Dental 
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 pay for a limited oral evaluation and extraction 
(D0140, D7140) provided on July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the cost for an out of network chiropractor visit provided 
on April 12, 2023. 
 
You asked the Plan to reimburse the cost for a chiropractic visit. You say that you should be reimbursed for this 
service. You have been in the past. 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 $400 deductible which applies to chiropractic services. As your 
deductible had not been met at the time of this service, you cannot be reimbursed for the $65 you paid. 
 
The item or service you asked the Plan to reimburse the cost for falls within the chiropractic services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 
deductible which applies to chiropractic services. This cost sharing is a contractual obligation that had not been 
met at the time a chiropractic visit was received on April 12, 2023. Therefore, we decided that the Plan does 
not have to reimburse the cost for an out of network chiropractor visit provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transportation (A0130) and ground 
mileage (S0209) provided on June 1, 2023. 
 You asked the Plan to pay for the wheelchair van transportation services. You say that you were never offered 
to schedule your own transportation before a nurse at the hospital scheduled the transport for you. The Plan 
denied your request. The Plan says this service was not provided by the Plan's designated provider. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation 
benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan 
covers routine transportation only when provided through the Plans designated provider. 
 
We looked at your request, the records in the case file, and the rules. This service was not provided by the Plans 
designated routine transportation provider. Based on this information, we decided that the Plans rules for coverage 
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pay for the 
wheelchair van transportation (A0130) and ground mileage (S0209) provided on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft (D7953), collection and application 
of autologous blood concentrate; (D7921), guided tissue regeneration (D4266), and an implant removal 
(D6100) provided on June 21, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 bone 
replacement graft (D7953), collection and application of autologous blood concentrate; (D7921), guided tissue regeneration (D4266), and an implant removal (D6100) provided on June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a bone replacement graft (D7953) provided on June 5, 
2023. 
 
You asked the Plan to pay more 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 June 5, 2023. Therefore, 
we decided that the Plan does not have to pay more for a bone replacement graft (D7953) provided on June 5, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the tint, the anti-reflective coating, the 
progressive lens, and the polycarbonate lens provided on June 20, 2023. 
 
You asked the Plan to pay for the frames, the tint, the anti-reflective coating, the progressive lens, and the 
polycarbonate lens. You say that you have diabetes and having issues with your eyes. You say the insurance 
should cover this claim. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of standard lenses and frames every two years. 
 
We looked at the file and the Plan's rules. Specifically, you received a pair of eyeglasses on July 14, 2022, 
which exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the 
frames, the tint, the anti-reflective coating, the progressive lens, and the polycarbonate lens have not been met. 
Therefore, we decided that the Plan does not have to pay for the frames, the tint, the anti-reflective coating, the 
progressive lens, and the polycarbonate lens provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 02, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are asking for the attached medical records to 
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 the office visit provided 
on December 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on July 5, 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 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 17, 2023. 
Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) provided on July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate mandibular partial denture (D5224) provided 
on February 28, 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 an 
immediate mandibular partial denture (D5224) provided on February 28, 2023.