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

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on February 
16, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says 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 dental services provided by an OON provider on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the intraoral 
radiographic image (D0220), and the bitewings (D0270) provided by an out-of-network provider on November 
18, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told that you are an in-network 
provider and would like the claim reprocessed. The Plan denied your request. The Plan says the dental services 
were received from an out-of-network provider and are not covered by the enrollees 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 the enrollee 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 the limited oral evaluation (D0140), the intraoral radiographic image (D0220), and the 
bitewings (D0270) provided by an out-of-network provider on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 31, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that this provider was previously in-network. The Plan 
denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the office visit provided on January 31, 2023, by an out-of-
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the replacement of the implantable 
defibrillator provided on November 10, 2022. 
 
You asked the Plan to waive the coinsurance for the replacement of the implantable defibrillator. You say that 
you were put into a coinsurance plan without your approval. 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 25% 
coinsurance for surgery services provided at hospital outpatient facilities.  
 
 
 You have been asked to pay $6,150.73, which is less than 25% coinsurance of the allowed amount for the 
replacement of implantable defibrillator procedure. This item/service falls within the outpatient surgery, 
including services provided at hospital outpatient facilities 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 the replacement of the implantable defibrillator provided on November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure provided on January 26, 2023, by an 
out-of-network (OON) provider.  
 
 You asked the Plan to pay for 2023. You say that you are requesting reconsideration. 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 therapeutic procedure provided on January 26, 
2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the MRI provided on January 25, 2023. 
 
You asked the Plan to reduce the cost share for the MRI. You say that you thought the MRI was performed by 
an in-network provider. 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 out-of-network outpatient diagnostic 
tests and therapeutic services and supplies. Your contract with the Plan clearly says that you must pay 50% 
coinsurance for out-of-network advanced imaging services. 
 
 
 You have been asked to pay $400, which satisfies the deducible for the MRI. The remaining allowed amount is 
$71.69 ($471.69 allowed amount - $400 deductible = $71.69). The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $400 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
the MRI was received on January 25, 2023.  
 
You have also been asked to pay $35.84, which is 50% coinsurance of the remaining allowed amount for the 
MRI ($71.69 remaining allowed amount x 50% = $35.84). 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 reduce the 
cost share for the MRI provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment  includes placement (D6057) 
and complete denture - mandibular (D6065) provided on October 28, 2022. 
 
You asked the Plan to pay for custom fabricated abutment and complete denture - mandibular. 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 custom 
fabricated abutment  includes placement (D6057) and complete denture - mandibular (D6065) provided on 
October 28, 2022.
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 
November 28, 2022, to December 24, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this was physical 
therapy. 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 $370 
copayment per day for days 1-4 of each in-network inpatient hospital stay. Your contract with the Plan also 
clearly says that you then pay a $0 copayment per day for days 5-90 of each in-network inpatient hospital stay. You have been asked to pay a $370 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 after day four 
or for the day you were discharged. You have been asked to pay a total of $1,480 for the inpatient hospital stay 
($370 copayment per day x 4 days = $1,480). 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 November 28, 2022, to December 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visit provided on 
December 7, 2022. 
 
You asked the Plan to waive the cost share for the specialist office visit. You say that you want the Plan to take 
care of these bills. 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 $1,000 which applies to out-of-network specialist office visits. Your 
contract with the Plan also says that you must pay 50% coinsurance after meeting the deductible for out-of-network specialist office visits. 
 
You have been asked to pay $137.47 towards the deductible. The item or service you asked the Plan to waive 
the cost share for falls within the physician/practitioner services benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $1,000 which applies to out-of-network 
specialist office visits. This cost sharing is a contractual obligation that had not been met at the time the 
specialist office visit was received on December 7, 2022.  
 
You have also been asked to pay $7.81, which is less than the standard 50% coinsurance for the specialist 
office visit. This item/service falls within the physician/practitioner services benefit category. You have been 
asked to pay a total of $145.28 for the specialist office visit ($137.47 deductible + $7.81 coinsurance = 
$145.28). 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 the specialist office visit provided on December 
7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on January 16, 2023, by an out-of-
network (OON) provider.  
 
 You asked the Plan to pay for an ultrasound. You say that you are requesting reconsideration. 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 an ultrasound provided on January 16, 2023, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Matrix glucose test strips. 
 
You asked the Plan to pre-approve the glucose test strips. You say that the enrollee already uses a True Matrix 
glucometer. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC 
are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the glucose test strips. Therefore, we decided that the Plan does not have to pre-approve True Matrix 
glucose test strips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen.  
 
You asked the Plan to pre-approve a CT scan of the abdomen. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the type of study requested is not supported for the 
enrollee's condition.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 a CT scan of the abdomen. Our 
reviewer says that the CT scan is not medically necessary. Our physician reviewer found the enrollee has 
imaging evidence of uncomplicated cirrhosis of uncertain etiology. Only a single elevation in alpha-fetoprotein 
(AFP) was provided, and not repeated for trending. Three imaging modalities of the liver between November 
19, 2021, and October 30, 2022 failed to identify any liver tumors. The CT scan cannot be approved at this 
time. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the abdomen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visits. You say that the enrollee is unlikely to seek help if the 
referral is denied. The Plan denied your request. The Plan says enrollees must receive their care from a network 
provider. 
 
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 
the office visits to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve the PT services with an OON provider. You say that the services are 
medically necessary for the enrollee as the network providers are a further distance. The Plan denied your 
request. The Plan says there are network providers that the enrollee can use. 
 
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 
physical therapy (PT) services to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the trabecular bone score exam provided on 
March 28, 2023. 
 
You asked the Plan to waive the copayment for the trabecular bone score exam. You say that you were 
unaware this was a diagnostic exam. 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for the trabecular bone score exam. This item/service falls within 
the physician/practitioner services, including doctors office visits 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 $39.76. Therefore, we decided that the Plan does not have to waive the 
copayment for the trabecular bone score exam provided on March 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the wound care supplies provided on 
February 20, 2023. 
 
You asked the Plan to waive the coinsurance for the wound care supplies. You say that the supplies arrived 
late, and you had no need for them. 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 each Medicare-covered durable medical equipment item.  
 
 
 You have been asked to pay 20% coinsurance for the wound care supplies. These items/services fall within the 
durable medical equipment and related supplies benefit category.  
 
Date of Service Item Allowed Amount 20% Coinsurance 
February 20, 2023 Dressing $382.80 $76.56 
February 20, 2023 Foam dressing $169.50 $33.90 
February 20, 2023 Gauze $9.00 $1.80 
 
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 the wound care supplies provided on February 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided from 
February 25, 2023, to March 8, 2023. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay. You say that you should not have 
to pay this large 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 $492 
copayment per day, for days 1-4 for inpatient hospital care.  
 
You were hospitalized for more than 4 days, resulting in a $1,968 copayment ($492 x 4 = $1,968). 
 You have been asked to pay a $1,968 for an in-network inpatient stay. 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 an in-
network inpatient stay provided from February 25, 2023, to March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #18 provided on January 
11, 2023. 
 
You asked the Plan to pay for the dental service. You say that the core buildup is a part of every crown service 
and should be fully covered. The Plan denied your request. The Plan says the denial of payment for this service 
is correct, because the core buildup is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #18 provided on January 11, 2023.