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

 
We decided that the Plan does not have to waive the coinsurance for in-network intravenous injections 
provided on January 10, 2023, to May 26, 2023. 
 
You asked the Plan to waive the coinsurance for in-network intravenous injections. You say that you cannot 
afford these copayments. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for in-network intravenous 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. The total you owe for the above dates of service is $4,034.97 total. 
Therefore, we decided that the Plan does not have to waive the coinsurance for in-network intravenous 
injections provided on January 10, 2023, to May 26, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have  to waive the copayment for ambulance transportation and an ER visit 
provided on June 01, 2023. 
 
You asked the Plan  to waive the copayment for ambulance transportation and an ER visit. You say that you 
were advised to go to the emergency department, but it was unnecessary. 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 $275 
copayment for ambulance services and a $90 copayment per emergency care visit.  You have been asked to pay a $365 copayment for ambulance transportation and an ER visit. The total includes 
a $275 copayment for ambulance transportation and a $90 copayment for an ER visit. The ambulance 
transportation falls within the ambulance services benefit category. The ER visit falls within the emergency 
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 ambulance transportation and an 
ER visit provided on June 01, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an MRI of the lumbar spine provided on July 31, 
2023. 
 
You asked the Plan to waive the copayment for an MRI of the lumbar spine. You say that the facility informed 
you that you are responsible for another copayment because you had a second MRI done. The Plan denied your 
request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for multiple MRI scans performed on the same day, during the same visit 
at a freestanding provider or outpatient hospital setting.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $95 
copayment for each MRI performed at a freestanding provider or outpatient hospital setting. The Plan contract 
does not specify that a separate copayment would be applied for multiple outpatient diagnostic tests performed 
on the same day, during the same visit, by the same provider. The medical records show that you have already 
been charged a $95 copayment for an MRI of the pelvis performed on July 31, 2023; Thus, you should not be 
charged another copayment for a second MRI performed during the same visit, by the same provider. This 
means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we 
decided that the Plan has to waive the copayment for an MRI of the lumbar spine provided on July 31, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete mandibular/maxillary dentures (D5120, D5110) 
provided on February 2, 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 cost-sharing applied correctly based on the 
services provided. 
 
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 a 40% coinsurance for complete maxillary/mandibular dentures. 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 complete 
mandibular/maxillary dentures (D5120, D5110) provided on February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on May 18, 2023. 
 
You asked the Plan to pay for lab testing. You say that you say that your doctor referred you for this service 
and it was not your choice. 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 lab testing provided on 
May 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the removal of skin and tissue provided on 
February 17, 2023. 
 
You asked the Plan to waive the copayment for the removal of skin and tissue. You say that you were billed for 
services that were not rendered. 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 $200 
copayment for Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical 
center.  
You have been asked to pay a $200 copayment for the removal of skin and tissue. This item/service falls within 
the Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical center 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 removal of skin and tissue provided on 
February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit on May 17, 2023.  
 
You asked the Plan to waive the deductible for an office visit. You say that you were billed $10 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 physician/practitioner services, 
including doctors office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $400 deductible which applies to physician/practitioner services, 
including doctors office visits. This cost sharing is a contractual obligation that had not been met at the time an 
office visit was received on May 17, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for an office visit on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment provided on May 29, 2023. 
 
You asked the Plan to pay for medication assisted treatment. 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 medication assisted 
treatment provided on May 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay provided on June 
26, 2023, to July 07, 2023. 
 
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that you were advised you 
needed to pay for days 1 to 4 only but in your current plan you have to pay for days 1 to 7. 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 $305 
copayment for inpatient hospital care. 
 
You have been asked to pay a $305 copayment for an inpatient hospital 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. You have been asked to pay a $2,135 copayment for an inpatient hospital stay ($305 per 
day x 7 days = $2,135). Therefore, we decided that the Plan does not have to reduce the copayment for an 
inpatient hospital stay provided on June 26, 2023, to July 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation, additional intraoral x-rays, 
cleaning, endosteal implants, custom fabricated abutment, abutment supported porcelain/ceramic crown 
(D0120, D1110, D0220, D0230, D6010, D6057, D6058) provided on May 10, 2022, to October 4, 2022. 
 
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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. The benefit for intraoral x-rays was already exhausted. Additionally, this benefit does not include 
endosteal implants, custom fabricated abutments, or abutment supported porcelain/ceramic crowns.  
 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. The 
benefit for intraoral x-rays was exhausted on May 10, 2022. Additionally, this benefit does not include 
endosteal implants, custom fabricated abutments, or abutment supported porcelain/ceramic crowns.  Therefore, 
we decided that the Plan does not have to pay more for a periodic oral evaluation, additional intraoral x-rays, 
cleaning, endosteal implants, custom fabricated abutment, abutment supported porcelain/ceramic crown 
(D0120, D1110, D0220, D0230, D6010, D6057, D6058) provided on May 10, 2022, to October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EsoGuard Esophageal DNA test (0114U) provided on 
May 25, 2023. 
 
You asked the Plan to pay for the EsoGuard Esophageal DNA test. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory providers who bill molecular 
diagnostic tests must register test services on the DEX Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The genetic testing in this case is not covered per the DEX 
Diagnostics Exchange. Based on this information, we decided that Medicare rules for coverage of the 
EsoGuard Esophageal DNA test have not been met. Therefore, we decided that the Plan does not have to pay 
for the EsoGuard Esophageal DNA test (0114U) provided on May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that a Freestyle Libre 2 would be easier to use. The Plan 
denied your request. The Plan says the enrollee has not met the medical criteria needed for this CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an injection provided on March 21, 2023. 
 
You asked the Plan to reduce the coinsurance for an injection. You say that the cost share applied is too 
expensive and you are requesting the cost be lowered. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an injection. This item/service falls within the Medicare Part 
B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. You have been asked to pay $276.80, which is 20% of the allowed amount for a Medicare Part B 
drug injection ($1,384.02 allowed x 20% = $276.80). Therefore, we decided that the Plan does not have to 
reduce the coinsurance for an injection provided on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling (D2391) provided on July 13, 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 September 16, 2021. 
Therefore, we decided that the Plan does not have to pay for a filling (D2391) provided on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) rendered on
September 21, 2022.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the documentation does not show that a local anesthetic was administered; therefore, the
scaling and root planing cannot be covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers periodontal
scaling and root planing and requires administration of local anesthesia by intramucosal injection for this
procedure.

We looked at the file and the Plan's rules. The original determination stated that the services were medically
necessary; however, the Plan did not deny the services based on medical necessity. The file clearly shows that
you declined the required local anesthesia by intramucosal injection due to having a high pain tolerance. The
Plan requires this anesthetic injection to be performed for the coverage of periodontal scaling and root planing.
Based on this information, we decided that the Plan's rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341)
rendered on September 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0152, G0157) provided on 
March 31, 2023, to April 29, 2023. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 31, 2023. The NOA was not received by the Plan until July 28, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, 
G0152, G0157) provided on March 31, 2023, to April 29, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services provided on December 01, 2022, to 
December 31, 2022. 
 
You asked the Plan to pay for dialysis services. You say that you are asking for the documents 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 dialysis services 
provided on December 01, 2022, to December 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each radiation treatment provided on May 
05, 2023, to May 12, 2023. 
 
You asked the Plan to waive the copayment for each radiation treatment. You say that you say that the charges 
exceed your out-of-pocket maximum. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $60 copayment for each radiation treatment. 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. The total you owe is $360 ($60 copayment x 6 
visits = $360). Therefore, we decided that the Plan does not have to waive the copayment for each radiation 
treatment provided on May 05, 2023, to May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the remote monitoring services provided on 
June 30, 2023. 
 
You asked the Plan to waive the copayment for the remote monitoring services. You say that the services were 
not rendered. 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 in-network telehealth. 
 
You have been asked to pay a $10 copayment for the remote monitoring services. This item/service falls within 
the in-network telehealth 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 remote 
monitoring services provided on June 30, 2023.