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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a complete upper 
denture (D5110), and a complete lower denture (D5120) provided on October 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that a restaurant threw your prior dentures out and 
getting a new set should be covered under your maximum benefit of $3,500. 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 your benefit for the comprehensive oral evaluation was exhausted on the date of service of June 6, 2022, 
and your benefit for the complete upper and lower dentures was exhausted on the date of service of July 28, 
2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a 
complete upper denture (D5110), and a complete lower denture (D5120) provided on October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. The Plan denied your request. The Plan says you do 
not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the fitness bike purchased on October 25, 2021. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says that this item is not a covered 
benefit. 
 
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. Specifically, the Health and wellness benefit language is indicated vaguely in the 
Plans 2021 contract. The Silver Sneakers fitness benefit stated does allow access for exercise equipment. This 
could give the impression that exercise equipment is covered. The timeframe to request reimbursement is not 
indicated in the Plans contract. Additionally, the 2021 Plan Notice to enrollees regarding the wellness benefit 
submitted in the case file, indicates that new cardiovascular fitness equipment is reimbursable. The Plan has not 
substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to 
issue reimbursement for the fitness bike purchased on October 25, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic socket replacement to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve prosthetic socket replacement. You say that you are requesting 
reconsideration. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 in Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plan's 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 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 
prosthetic socket replacement 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 pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary. The Plan denied your 
request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, or  require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 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 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve these 
services. 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 October 7, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an out-of-network specialist office visit 
provided on August 24, 2022. 
 
You asked the Plan to waive the cost share for an out-of-network specialist office visit. 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. Your 
contract with the Plan says that there is a $250 deductible and a $40 copayment which applies to out-of-
network physician/practitioner services/specialist.  
 
The item or service you asked the Plan to waive the cost share for falls within the out-of-network 
physician/practitioner services/specialist benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $250 deductible and a $40 copayment which applies to out-of-network 
physician/practitioner services/specialist. You are being asked to pay $76.27 towards your deductible. The total 
amount you are being asked to pay is $116.27 ($76.27 + $40 = $116.27). This cost sharing is a contractual 
obligation that had not been met at the time an out-of-network specialist office visit was received on August 24, 
2022. Therefore, we decided that the Plan does not have to waive the cost share for an out-of-network specialist 
office visit provided on August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-preferred diabetic supplies. 
 
You asked the Plan to pre-approve non-preferred diabetic supplies. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the non-preferred brand diabetic test strips 
are not medically necessary as the enrollee can enter data manually. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those 
preferred brands and manufacturers, if certain conditions in the rules section are met. 
 
We looked at the file, the Plan's contract, and Medicare rules. The Plan contract shows that diabetic supplies 
are limited to the Plan's preferred manufacturer unless there is a medical justification provided that the enrollee 
would need the non-preferred brand. In this case, the enrollee is requesting the non-preferred brand test strips 
because they automatically link to their insulin pump. This is for convenience and is not based on medical 
necessity. The Plan has shown there are preferred brand products available to the enrollee and that the enrollee 
could also manually enter their data to their insulin pump. Therefore, we decided that the Plan does not have to 
pre-approve non-preferred diabetic supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5120 
and D5110). 
 
You asked the Plan to pre-approve the dental services. You say that your previous dentures do not fit. 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 October 2, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture 
(D5120 and D5110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mammography to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve mammography. You say that 2023 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 in Chapter 3). In most cases, care the enrollee receives from an out-of-network provider (a provider who is 
not part of the plan's 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 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 
mammography to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the mental health services. You say that you have been seeing this provider 
and would like an exception to continue care. The Plan denied your request. The Plan says the provider is not 
in the Plan's network. Network providers are available to continue necessary care. 
 
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 
mental health services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D; 25 hydroxy testing (82306) provided on June 
1, 2022. 
 
You asked the Plan to pay for the Vitamin D testing. You say that this service should be covered. The Plan 
denied your request. The Plan says screening services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the Vitamin D hydroxy testing, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the Vitamin D; 25 hydroxy testing (82306) provided on June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 18, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing aids (V5298 x 2) purchased on 
March 1, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for additional 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $375 copayment for each silver level hearing aid.  
 
The enrollee has been asked to pay a $375 copayment for the hearing aids purchased in this case. The provider 
billed the Plan in the amount of $2,000 for the hearing aids purchased. The Plans allowed amount for this 
purchase was $500. The Plan issued payment in the amount of $125 as the enrollees copayment liability is 
$375. The Plan contract states that enrollees must pay a $375 copayment for each silver level hearing aid. The 
enrollee was charged for only one copayment although two hearing aids were purchased in this case. 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 the hearing aids (V5298 x 2) purchased on 
March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular dentures 
(D5120/D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve these 
dentures. 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 June 21, 2018. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary and mandibular dentures 
(D5120/D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the enrollee needs these custom 
compression stockings. The Plan denied your request. The Plan says the requested compressions stockings 
have been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on September 27, 2022. 
 
You asked the Plan to pay for the dental services. 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 service was exhausted on date of service May 12, 2022. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided on 
September 27, 2022.