Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for durable medical equipment (DME) 
provided on July 25, 2022. 
 
You asked the Plan to waive the copayment for DME. 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 
$1509.49 cost share for Section 2.4 How to get care from out-of-network providers and durable medical 
equipment (DME)/You must obtain DME & related supplies from a licensed DME provider.  
 
You have been asked to pay a $1,509.49 cost share for DME. You are being asked to pay the full amount of 
$1,509.49. This item/service falls within the Section 2.4 How to get care from out-of-network providers and 
Durable medical equipment (DME)/You must obtain DME &related supplies from a licensed DME provider. 
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 durable medical equipment 
(DME) provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on September 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the claim from January 10, 2022, was a 
fraudulent claim. 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 January 10, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
complete series of intraoral x-rays (D0210) provided on September 21, 2022.   
Your complaint about the claim from January 10, 2022, being a fraudulent claim 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic eye appointment provided on August 08, 2022. 
 
You asked the Plan to pay for a diagnostic eye appointment. 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 diagnostic eye 
appointment provided on August 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided from 
October 21, 2021, to January 27, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that you disagree with the 
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 $25 
copayment per visit for physician/practitioner services/specialist.  
 
You have been asked to pay a $25 copayment per visit for specialist office visits. The total amount you are 
being asked to pay is $375 ($25 x 15 = $375). This item/service falls within the physician/practitioner 
services/specialist 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 specialist office 
visits provided from October 21, 2021, to January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for anesthesia provided on July 29, 2022. 
 
You asked the Plan to waive the deductible for anesthesia. You say that you disagree with the deductible. 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 $1,500 
deductible for Section 1.2 What is your plan deductible? 
 
You have been asked to pay a $1,500 deductible for anesthesia. You are being asked to pay $289.77 towards 
your deductible. This item/service falls within the Section 1.2 What is your plan deductible? 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 deductible for anesthesia provided on July 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported removable denture (D6111). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
implant supported removable denture 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 an 
implant supported removable denture (D6111).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit provided on 
June 22, 2022. 
 
You asked the Plan to waive the copayment for the emergency room (ER) visit. You say that you refused 
treatment and should not have to pay. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room (ER) visit. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
(ER) visit provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), and 
comprehensive periodontal evaluation - new or established patient (D0180) provided on August 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were informed by the Plan that you were 
eligible for the comprehensive periodontal evaluation. You also say that since you were misinformed you 
shouldn't be charged. 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 August 12, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330), and 
comprehensive periodontal evaluation - new or established patient (D0180) provided on August 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says admission to an IRF is not medically necessary. 
 
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 that you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you may have a need 
for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee brace (L1830), provided on June 27, 2022. 
 
You asked the Plan to pay for the knee brace. You say that the item is medically necessary. The Plan denied 
your request. The Plan says records show the enrollee does not have recent injury, knee surgery or objective 
evidence of instability. 
 
The Plan must follow Medicare rules. Medicare rules say that a knee immobilizer without joints (L1830) is 
covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s) or when knee 
instability is documented by examination of the beneficiary and objective description of joint laxity. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee brace have not been met. Specifically, there is no record of recent injury, knee surgery or 
objective evidence of instability for this enrollee. Therefore, we decided that the Plan does not have to pay for 
the knee brace (L1830), provided on June 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided to the 
enrollee on August 8, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the enrollee should not be 
responsible for this trip due to catching COVID-19 during his first hospital stay. 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 $250 copayment for ambulance services.  
 
The enrollee has been asked to pay $238.54, which is less than the $250 copayment for the ambulance services. 
This item/service falls within the ambulance services 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 ambulance services provided to the enrollee on August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic image 
(D0350), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on 
August 1, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic image, comprehensive oral evaluation, and 
complete series of intraoral x-rays. You say that you think it is only fair, since you paid almost all of your 
expenses in 2021, and since your dentist is retiring, the expenses incurred for this dental treatment should be 
payable. The Plan denied your request. The Plan says the 2D oral/facial photographic image is not a covered 
benefit under your dental plan. The Plan also says that the comprehensive oral evaluation and complete series 
of intraoral x-rays exceed the frequency limitations in the 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 2D oral/facial photographic image 
(D0350) is not among those covered under this benefit. The contract says that comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of 
intraoral x-rays (D0210) on January 13, 2021, and your comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not 
have to pay for the two dimensional (2D) oral/facial photographic image (D0350), comprehensive oral 
evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on August 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve aide services. You say that you need an aide at home to help with basic 
daily activities. The Plan denied your request. The Plan says the requested services are not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of aide services have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home health 
aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gel pads (K0108). 
 
You asked the Plan to pre-approve the gel pads. You say that you need this item. The Plan denied your request. 
The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the gel pads (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on provided on 
August 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for principal care management services. 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 advanced. 
 
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 principal care management services provided on 
provided on August 5, 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 compression stockings identified with code A6537. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need this item. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6537 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6537.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax incurred on a wheelchair purchase (S9999), 
purchased on June 14, 2022. 
 
You asked the Plan to pay for the sales tax. You say that this should be covered. The Plan denied your request. 
The Plan says sales tax is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales 
tax. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax incurred on a wheelchair purchase (S9999), purchased on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 12, 2022. Therefore, 
we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you would like to see another provider since 
you feel current treatment is ineffective. The Plan denied your request. The Plan says network providers are 
available to provide 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 
an office visit 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 laboratory services related to end-stage renal disease 
(ESRD) provided on June 20, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the codes billed are payable. 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 June 20, 
2022.