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

 
We decided that the Plan does not have to pay more for a retainer crown (D6740) and to pay for a periodic oral 
evaluation (D0120), an application of fluoride (D1206), a prefabricated post and core (D2954), a pontic 
(D6245), a retainer crown (D6740), and an extraction (D7210) provided by The Wheelchair Store on July 25, 
2022, and October 10, 2022 
 
You asked the Plan to pay more for the dental services. You say that you were told that the Plan would pay 
$1,000 towards the bridge work. The Plan denied your request. The Plan says the enrollee's dental maximum 
benefit for the year 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 $119.23 for dental services on February 21, 2022. On June 27, 2022, the Plan paid $72 for 
dental services. On July 25, 2022, the Plan paid $832 for dental services. For the year of 2022 the Plan paid 
$1,023.23 ($119.23 paid + $72 paid + $832) for dental services; therefore, the enrollees dental maximum 
benefit for the year of 2022 was exhausted on the date of service of July 25, 2022. Therefore, we decided that 
the Plan does not have to pay more for a retainer crown (D6740) and to pay for a periodic oral evaluation 
(D0120), an application of fluoride (D1206), a prefabricated post and core (D2954), a pontic (D6245), a 
retainer crown (D6740), and an extraction (D7210) provided by The Wheelchair Store on July 25, 2022, and 
October 10, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the eye examination, the visual field test, 
and the gonioscopy provided on July 11, 2023. 
 
You asked the Plan to reduce the copayment for the eye examination, the visual field test, and the gonioscopy. 
You say that you normally pay a $40 copayment but this time you are paying $85.58 for testing. 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 $40 
copayment for a Medicare-covered exam (diagnosis and treatment for diseases and conditions of the eye) and 
$100 copayment diagnostic procedures.  
 
You have been asked to pay a $40 copayment for the eye examination. You have also been asked to pay a 
$85.58 copayment, which is less than the standard amount, for the visual field test and the gonioscopy. The eye 
examination falls within the vision care benefit category. The visual field test and the gonioscopy fall 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 copayment for the eye examination, the visual field test, and the gonioscopy provided on July 11, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite (D2330), prophylaxis-adult 
(D1110), periodic oral evaluation (D0120), limited oral evaluation (D0140), intraoral- periapical first 
radiographic image (D0220), and intraoral- periapical each additional radiographic image (D0230) provided on 
May 4, 2023, to June 5, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 contract also says that a limited oral 
evaluation is not a covered service. Intraoral- periapical first radiographic image and intraoral- periapical each 
additional radiographic image is covered 1 procedure code per calendar year.  
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 resin-based composite (D2330), 
prophylaxis-adult (D1110), periodic oral evaluation (D0120), limited oral evaluation (D0140), intraoral- 
periapical first radiographic image (D0220), and intraoral- periapical each additional radiographic image 
(D0230) provided on May 4, 2023, to June 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on June 19, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the home visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
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 the home visit provided on June 19, 2023, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on June 20, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the laboratory service provided on June 20, 2023, 
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on July 18, 2023. 
 
You asked the Plan to pay for physical therapy services. You say that there was an authorization for these 
services. 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 physical therapy 
services provided on July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewings (D0274), 
and a cleaning (D1110) provided by an out-of-network provider on August 31, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are appealing the liability for the 
dental services. 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. 
 
  The total amount billed for the periodic oral evaluation (D0120) was $43 and the total allowed amount was $19 
leaving a difference of $24 ($43 billed - $19 allowed). The total amount billed for the bitewings (D0274) was 
$57 and the total allowed amount was $26 leaving a difference of $31 ($57 billed - $26 allowed). The total 
allowed amount for the cleaning (D1110) was $107 and the total allowed amount was $41 leaving a difference 
of $66 ($107 billed - $41 allowed). 
 
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 periodic oral evaluation (D0120), 
bitewings (D0274), and a cleaning (D1110) provided by an out-of-network provider on August 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluoroscopic guidance procedure provided on May 26, 
2023. 
 
You asked the Plan to pay for a fluoroscopic guidance procedure. You say that this was medically necessary 
and should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a fluoroscopic guidance 
procedure provided on May 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sedation (D9239 and D9243). 
 
You asked the Plan to pre-approve the dental services. You say that you need the sedation in order to receive 
the surgery. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because sedation 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
sedation (D9239 and D9243).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 13, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on July 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service May 30, 
2023. 
 You asked the Plan to pay for procedure code 99140. You say that you are requesting the claim be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says procedure code 99140 is considered 
bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service May 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on July 19, 2023. 
 
You asked the Plan to pay for the podiatry services. 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 podiatry services 
provided on July 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) and 
computed tomography (CT) scan provided on July 7, 2023, and July 17, 2023. 
 
You asked the Plan to waive the copayment for the MRI and CT scan. You say that you should not have to pay 
for the test you received. 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 $195 
copayment for each Medicare-covered CT scan and a $195 copayment for each Medicare-covered diagnostic 
radiology service other than CT scans.  
 
  You have been asked to pay a total of $390 for the MRI and CT scan ($195 + $195 = $390). These 
items/services fall 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 waive the copayment for the magnetic resonance imaging (MRI) and computed 
tomography (CT) scan provided on July 7, 2023, and July 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a regadenoson injection and the myocardial 
perfusion imaging 
 
You asked the Plan to reduce the cost share for an injection and the myocardial perfusion imaging. You say 
that you were not told of the of the cost share. 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. Your contract with the Plan clearly says that you must pay 
a $200 copayment for nuclear medicine cardiac stress tests. 
 
You have been asked to pay $64.72, which is 20% coinsurance of the allowed amount for an injection ($323.63 
allowed amount x 20% = $64.72). 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 also been asked to pay a $200 copayment for the myocardial perfusion imaging. 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 a regadenoson injection and the myocardial perfusion imaging
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant removal (D6100), bone replacement graft for ridge 
preservation (D7953) and guided tissue regeneration - resorbable barrier, per site (D4266) provided on January 
13, 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 these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for implant 
removal (D6100), bone replacement graft for ridge preservation (D7953) and guided tissue regeneration - resorbable barrier, per site (D4266) provided on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a facet injection and a dexamethasone 
injection provided on March 22, 2023. 
 
You asked the Plan to waive the cost share for a facet injection and an injection. You say that you disagree with 
the cost share. 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 $25 
copayment per visit to a specialist. 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 a $25 copayment for a facet injection. 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.  
 
You have also been asked to pay $0.25, which is 20% coinsurance of the allowed amount for the injection 
($1.25 allowed amount x 20% = $0.25). This item/service falls within the Medicare Part B prescription drugs 
benefit category. You have been asked to pay a total of $25.25 ($25 copayment + $0.25 coinsurance = $25.25). 
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 a facet injection and a dexamethasone injection provided on 
March 22, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on June 20, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the x-rays and an office visit on June 21, 
2023. 
 
You asked the Plan to waive the copayments for the x-rays and an office visit. You say that you just don't want 
to have to pay for another x-ray and copay for something that wasn't your fault. 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 $20 
copayment for each basic imaging service (e.g., general x-rays or ultrasound). You must pay a $30 copayment 
for each in-person specialist visit. For both services it's, $20 + $30 = $50. Therefore, results in the total cost 
sharing amount of $50. 
 
You have been asked to pay a $20 copayment for the x-rays and a $30 copayment for an office visit. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies and 
physician/practitioner services, including doctor's 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. Therefore, we decided that the Plan does not have 
to waive the copayments for the x-rays and an office visit on June 21, 2023.