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

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on May 19, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you did not 
realize the CT scan and the MRI would be separate 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 a $325 
copayment for outpatient diagnostic tests.  
You have been asked to pay a $325 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 $320.19, which is less than the standard copayment for 
an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
imaging (MRI) provided on May 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service provided on February 28, 2023. 
 You asked the Plan to pay for the ambulance service. You say that the enrollee was transported due to an 
assault where they were choked resulting in decreased loss of consciousness and hypotension. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service provided on February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided by an out-of-network 
provider on July 18, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the dental service was 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 service from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested item or service are not covered under this 
benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to 
pay for a consultation (D9310) provided by an out-of-network provider on July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the palliative treatment (D9110) provided on June 6, 2023. 
 
You asked the Plan to pay for the dental service. You say that the Plan has inappropriately combined the 
service codes and the palliative treatment should have a separate 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. 
 
  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 April 25, 2023, and May 30, 2023; therefore, your 
benefit for the requested item or service was exhausted on the date of service of May 30, 2023. Therefore, we 
decided that the Plan does not have to pay for the palliative treatment (D9110) provided on June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) and a 
determination of refractive state (92015) provided on June 29, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014) and a determination of 
refractive state (92015). You say that you are appealing with supporting records. 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 examination to diagnose and treat diseases and conditions of the eye. 
 
You have been asked to pay a $35 copayment for a medical eye examination (92014) and a determination of 
refractive state (92015). This item/service falls within the examination to diagnose and treat diseases and conditions of the eye 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 record shows this was a diagnostic eye examination and not a routine eye examination. 
Therefore, we decided that the Plan does not have to waive the copayment for a medical eye examination 
(92014) and a determination of refractive state (92015) provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electroencephalogram provided on February 27, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for an EEG. You say that you believe that the denial was not justified and is 
appealing the claim determination. 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 electroencephalogram provided on February 
27, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic evaluation (D0120), bitewing x-rays-four 
radiographic films (D0274), dental cleaning (D1110), intraoral-periapical first radiographic image (D0220), 
and the resin-based composite-two surfaces, posterior (D2392) provided from June 20, 2023, through June 21, 
2023. 
 
You asked the Plan to pay for the dental items/services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says the dental items/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 dental items/services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the items/services provided 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 periodic evaluation (D0120), bitewing x-rays-four radiographic films (D0274), dental cleaning 
(D1110), intraoral-periapical first radiographic image (D0220), and the resin-based composite-two surfaces, 
posterior (D2392) provided from June 20, 2023, through June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the intraoral  comprehensive series of radiographic images (D0210) 
provided on July 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the dental office to be 
responsible for the cost of the x-rays. You also say that this is because the dental office lied about the coverage, 
the number of x-rays that were taken and for wanting to provide unnecessary treatment. The Plan denied your 
request. The Plan says that our records indicate that a claim was benefited for an x-ray D0210. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We did not receive any evidence that the Plan had already paid the claim for the 
x-ray D0210 on September 16, 2021. The Plan did not support or substantiate their denial reason. Therefore, 
we decided that the Plan has to pay for the intraoral  comprehensive series of radiographic images (D0210) 
provided on July 6, 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. 
 
Your complaint about the dental office is not a valid appeal for medical coverage. This part of your complaint 
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these 
types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 7, 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 your $500 annual maximum 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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultra-violet (U-V) lenses (V2755), anti-glare lenses (V2750) 
and high index lenses (V2783) are excluded from this benefit provided on June 12, 2023. 
 
You asked the Plan to pay for ultra-violet (U-V) lenses (V2755), anti-glare lenses (V2750) and high index 
lenses (V2783). You say that these glasses are essential to wear while riding your motorcycle. The Plan denied 
your request. The Plan says these are services are not covered by the Plan. 
 
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 lenses when they are single vision or lined multi-focal lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that the vision care allowance covers standard 
single vision or lines multi-focal lenses and frames. Ultra-violet (U-V) lenses (V2755), anti-glare lenses 
(V2750) and high index lenses (V2783) are excluded from this benefit. Based on this information, we decided 
that the Plan's rules for coverage of ultra-violet (U-V) lenses (V2755),anti-glare lenses (V2750) and high index 
lenses (V2783) have not been met. Therefore, we decided that the Plan does not have to pay for ultra-violet (U-
V) lenses (V2755), anti-glare lenses (V2750) and high index lenses (V2783) are excluded from this benefit 
provided on June 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for x-rays provided on June 02, 2023. 
 
You asked the Plan to waive the coinsurance for x-rays. You say that you say that you never had to pay for 
tests before and you dont think you are supposed to pay for the test. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 20% coinsurance for x-rays. 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 $60.33 ($301.67 allowed amount x 20% = 
$60.33). Therefore, we decided that the Plan does not have to waive the coinsurance for x-rays provided on 
June 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on April 25, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial with supporting 
documentation. 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 laboratory service 
provided on April 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis, aspiration and/or 
injection, of the small joint or bursa; without ultrasound guidance (20600) provided on March 9, 2023. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 $325 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.   
  
 
 
You have been asked to pay a $252.09 copayment for the Medicare-covered outpatient surgery provided. This 
is the Plans allowed amount for this service and is less than the applicable copayment. 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 arthrocentesis, aspiration and/or injection, of the small joint or 
bursa; without ultrasound guidance (20600) provided on March 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
from March 10, 2023, to March 11, 2023. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that you do not feel 
the plan paid enough on this claim. 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 $395 
copayment per day, for days 1-4 for inpatient hospital services.  
 
You have been asked to pay a $395 copayment for an in-network acute inpatient stay. This item/service falls 
within the inpatient hospital services benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an in-network acute inpatient stay provided from March 10, 
2023, to March 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were referred to this oral surgeon by the 
endodontics prior to having a root canal procedure. 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 April 27, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit, and pelvis x-rays provided 
on May 22, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit, and pelvis x-rays. You say that this 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 a hospital outpatient 
clinic visit, and pelvis x-rays provided on May 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on June 19, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you sprayed cleaning solution into your 
eye and when you were in the hospital the physician administered eye drops for relief. You say that you were 
never advised to use a self-administered drug, nor did you use a self-administered drug. The Plan denied your 
request. The Plan says that self-administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on June 19, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for restorative foundation for an indirect restoration (D2949) 
provided on May 30, 2023. 
 
You asked the Plan to pay for restorative foundation for an indirect restoration (D2949). You say that the 
dentist said that this would be covered. The Plan denied your request. The Plan says this service is listed as a 
non-covered expense. 
 
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 
restorative foundation for an indirect restoration (D2949) provided on May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on May 
13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the x-rays were medically necessary for your 
left side of your mouth. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 the intraoral radiographic image (D0220) on May 13, 2023; therefore, your benefit for 
the requested items or services was exhausted on the date of service of May 13, 2023. Therefore, we decided 
that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on May 13, 2023.