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

 
We decided that the Plan does not have to pre-approve labial veneers (D2962) for teeth # 6, 7, 9, 10, and 11. 
 
You asked the Plan to pre-approve labial veneers. You say that you want to get this done. You also say that you 
need the service. The Plan denied your request. The Plan says labial veneers are 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 labial veneers are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
labial veneers (D2962) for teeth # 6, 7, 9, 10, and 11.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $400 copayment for an endoscopy performed on October 
6, 2021. 
 
You asked the Plan to waive your $400 copayment for an endoscopy performed on October 6, 2021. You say 
that you were told this would be fully paid by your insurance company. The Plan denied your request. The Plan 
says you are responsible to pay a $400 copayment for all other Outpatient Services not provided in an 
Ambulatory Surgical Center. 
 
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 $400 
copayment for Outpatient Surgery, Including Services Provided At Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.   
You have been asked to pay a $400 copayment for an endoscopy. An endoscopy falls within the Outpatient 
Surgery, Including Services Provided At Hospital Outpatient Facilities and Ambulatory Surgical Centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive your $400 copayment for an endoscopy performed 
on October 6, 2021.  
 
Your complaint about being given incorrect information about your cost share responsibility 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 pre-approve a pontic (D6210), retainer crown (D6752), and retainer 
crown (D6792). 
 
You asked the Plan to pre-approve the pontic and retainer crowns. The Plan denied your request. The Plan says 
these services are not covered under your benefit 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 a 
pontic (D6210), retainer crown (D6752), and retainer crown (D6792).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite-two surfaces, anterior for teeth 
number 8 and 9 (D2331), a resin-based composite-three surfaces, posterior for tooth number 21 (D2393), and a 
resin-based composite-one surface, anterior for tooth number 22 (D2330). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the allowable benefit has been exhausted for the 
services requested in this case.  
 
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. Two restorative services are 
covered per calendar year.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the restorative services requested are covered twice 
per calendar year.  The record shows that the enrollee previously received an amalgam-three surfaces 
filling (D2160) and a resin-based composite-two surfaces posterior (D2392) on February 9, 2022. Therefore, 
the enrollee has exhausted the allowable benefit for the services requested in this case for this calendar year. 
Therefore, we decided that the Plan does not have to pre-approve a resin-based composite-two surfaces, 
anterior for teeth number 8 and 9 (D2331), a resin-based composite-three surfaces, posterior for tooth 
number 21 (D2393), and a resin-based composite-one surface, anterior for tooth number 22 (D2330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic images (D0350), oral 
hygiene instructions (D1330), unspecified periodontal procedures (D4999), and the gingival irrigationper 
quadrant (D4921) provided from March 14, 2022, through March 15, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial 
photographic images (D0350), oral hygiene instructions (D1330), unspecified periodontal procedures (D4999), 
and the gingival irrigationper quadrant (D4921) provided from March 14, 2022, through March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an out-of-network provider. 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says there are in-network providers available to provide the requested 
dental 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. The Plan covers covered 
dental services when the services are provided by a participating provider.  
 
We looked at the file, and Medicare rules. There are in-network providers available within a 50 mile radius that 
can provide these services. Based on this information, we decided that the Plan's rules for coverage of dental 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services 
provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-network coverage for an oral device for obstructive 
sleep apnea (E0486) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve in-network coverage for an oral device for obstructive sleep apnea. You say 
that this request is for your sleep apnea device which you received from this OON provider 7 years ago. You 
also say that you tried contacting alternative providers, left voicemails for them, but have not gotten a response. 
The Plan denied your request. The Plan says benefit coverage cannot be provided for in-network coverage for 
an out of plan referral. The Plan also says that there are network providers available with the appropriate 
training and experience to provide this service. 
 
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 
in-network coverage for an oral device for obstructive sleep apnea (E0486) to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the durable medical equipment (DME) supplies 
provided on September 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to reimburse for the DME supplies. You say that you were unaware that you could not use 
the OON provider for the DME supplies. The Plan denied your request. The Plan says the enrollee obtained the 
DME supplies from an OON provider and there are in-network providers that can provide the supplies the 
enrollee needs. 
 
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 reimburse 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 reimburse for these items/services. 
Therefore, we decided that the Plan does not have to reimburse for the durable medical equipment (DME) 
supplies provided on September 28, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81210, 81235, 81272, 81275, 
81276, 81292, 81301, and 81311) provided on October 4, 2021. 
 
You asked the Plan to pay for codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 81311. 
You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The 
Plan says the services are not covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 81311) 
provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four biologic materials to aid in soft and osseous tissue 
regeneration (D4265 x4) and two primary closures of a sinus perforation (D7261 x2). 
 
You asked the Plan to pre-approve the biologic materials and primary closures of a sinus perforation. The Plan 
denied your request. The Plan says these services are not covered under your benefit 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 four 
biologic materials to aid in soft and osseous tissue regeneration (D4265 x4) and two primary closures of a sinus 
perforation (D7261 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that your primary care physician did provide 
a referral to the chiropractor, and you have a copy of it. The Plan denied your request. The Plan says the 
request does not meet the Medicare or health plan coverage criteria. 
 
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 chiropractic services at issue in this appeal. We found no exception that would 
require the Plan to pre-approve these chiropractic services. Therefore, we decided that the Plan does not have to 
pre-approve chiropractic services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home Covid-19 testing provided on December 26, 
2021, and December 31, 2021. 
 
You asked the Plan to pay for the testing services. You say that the president stated the tests would be covered 
by insurance. The Plan denied your request. The Plan says the testing was received prior to when the benefit 
went in to affect. 
 
The Plan must follow Medicare rules. The Centers for Medicare and Medicaid Services says that beginning 
April 4, 2022, until the COVID-19 public health emergency (PHE) ends, people with Medicare Part B can get 
up to eight free over-the-counter tests for the month of April any time before April 30 and can then get another 
set of eight free over-the-counter tests during each subsequent calendar month through the end of the COVID-
19 PHE. The Plans policy begins coverage as of February 15, 2022. The services at issue were provided before 
coverage began. Therefore, we decided that the Plan does not have to pay for the at-home Covid-19 testing 
provided on December 26, 2021, and December 31, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for electrical stimulator supplies, 2 lead, per month (A4595) provided 
January 30, 2022. 
 
You asked the Plan to pay for electrical stimulator supplies. You say that this enrollee received a Tens Unit 
E0730 which processed for benefit under another claim. Per the Plan, if a 4 tens lead are necessary, a maximum 
of 2 unites of a Tens supply allowance would be considered medically necessary per month. The Plan denied 
your request. The Plan says that experimental and investigational services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for electrical stimulator supplies. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found this is a chronic pain condition other than low back pain which should be responsive 
to TENS. The request is considered medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electrical stimulator supplies have been met. Therefore, we decided that the 
Plan has to pay for electrical stimulator supplies, 2 lead, per month (A4595) provided January 30, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on March 21, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it was medically necessary to treat the 
enrollee and you would like the claim processed for payment. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. 
 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 nursing facility care provided on March 21, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity, below knee/above knee 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an addition to lower extremity, below knee/above knee. You say that you 
are appealing with supporting records. The Plan denied your request. The Plan says this service is a network 
lock-in, and medically necessary care is available in-network. 
 
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 
an addition to lower extremity, below knee/above knee to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Office visit on April 29, 2021, September 
16, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that the enrollee had no way of 
understanding this plan because she doesn't understand the language. The Plan denied your request. The Plan 
says the cost-sharing amount the enrollee is being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $5 copayment for each primary care visit. Covered services include: Medically-necessary medical 
care or surgery services furnished in a physicians office, certified ambulatory surgical center, hospital 
outpatient department, or any other location. There were 2 visits, resulting in a total copayment amount of $10.  
 
The enrollee has been asked to pay a $5 copayment for office visit. Office visit falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for Office visit on April 29, 2021, September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an 
OON provider. 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this is the only provider in 
the enrollee's geographical area with clinical documentation that specializes in the Airos Brand lymphedema 
pump.  The Plan denied your request. The Plan says there are in-network providers in the area. 
 
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 OON 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 
a pneumatic compression device to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets all applicable Medicare criteria 
for admission to an acute inpatient rehabilitation setting (ARU/IRF). You also say that it is your professional 
opinion that she will receive the appropriate level of care that she needs in this setting. The Plan denied your 
request. The Plan says based on Medicare guidelines, the services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.