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

 
We decided that the Plan does not have to pay for the hearing aids, digital, monaural, behind the ear (V5257) 
provided on August 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that this provider was on a list provided by the Plan. 
The Plan denied your request. The Plan says this service is not provided OON. Additionally, the Plan states 
they can find no records of a provider list being provided. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when rendered by a provider in the Plan's hearing aid network. 
 
We looked at the file and the Plan's rules. In this case the hearing aids were provided OON. Based on this 
information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we 
decided that the Plan does not have to pay for the hearing aids, digital, monaural, behind the ear (V5257) 
provided on August 4, 2022, by an out-of-network (OON) provider.  
 
Your complaint about potentially receiving misinformation from the Plan 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 pre-approve an office visit consult to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit consult. You say that you are unable to see a network 
provider within the requested timeframe. 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 consult to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a battery for use in a hearing device (V5266) provided on 
September 21, 2022. 
 
You asked the Plan to pay for a battery for use in a hearing device (V5266). You say that you do not have a 
hearing aid, you have a cochlear implant. You also say that batteries and accessories should be covered under 
the Plan and would like this claim to be reconsidered and reimbursed. The Plan denied your request. The Plan 
says there is no coverage for batteries made separate from a covered hearing aid purchase, 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through the Plan's specific branded hearing aids every year.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a battery for use in a hearing device (V5266)  have not been met. Therefore, we decided that the 
Plan does not have to pay for a battery for use in a hearing device (V5266) provided on September 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery provided on June 06, 2022. 
 
You asked the Plan to pay for the cataract surgery. You say that you were informed that no pre-authorization 
was required. 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 cataract surgery 
provided on June 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 04, 2022. 
 
You asked the Plan to pay for the office visit. You say that the provider works in the same facility and should 
be in network. 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 office visit provided 
on October 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown provided on July 18, 2022. 
 
You asked the Plan to pay for the crown. You say that the services should be covered as you disagree with 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 03/03/2022 and 
03/16/2022. Therefore, we decided that the Plan does not have to pay for a crown provided on July 18, 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 there are no network providers that can 
perform the necessary procedure. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an impacted tooth removal (D7240) provided by a 
participating provider. 
 
You asked the Plan to pre-approve an impacted tooth removal. You say that you would like approval for these 
services. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
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 
impacted tooth removal (D7240) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the over-the-counter allowance from the first quarter. 
 
You asked the Plan to pre-approve the over-the-counter allowance from the first quarter. You say that you did 
not realize this program was available. You also say you would like to have the first quarter since you were not 
aware of it. The Plan denied your request. The Plan says according to the EOC, quarterly allowances cannot be 
carried over to another quarter. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the over-
the-counter allowance from the first quarter is an OTC item. Therefore, we decided that the Plan does not have 
to pre-approve the over-the-counter allowance from the first quarter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit provided on June 27, 2019. 
 
You asked the Plan to pay for outpatient visit. You say that you are appealing the claim payment denial. 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 outpatient visit provided 
on June 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a continuous glucose monitor and supplies (K0554, K0553) 
 
You asked the Plan to provide the continuous glucose monitor and supplies. You say that the services should be 
covered as the enrollee disagrees with the denial and the monitor is medically necessary. The Plan denied your 
request. The Plan says the services denied correctly as they do not meet the clinical requirements to be 
approved, the record indicates that the enrollee only injects insulin twice a day, therefore cannot be approved. 
 
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, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the continuous glucose monitor and supplies have 
not been met. Therefore, we decided that the Plan does not have to provide a continuous glucose monitor and 
supplies (K0554, K0553)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 7, 2022. 
 
You asked the Plan to pay for the evaluation. You say that you disagree with the denial of 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 item or service was exhausted on date of service May 12, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid provided on January 12, 2022. 
 
You asked the Plan to pay for the hearing aid. You say that you are appealing the denial. The Plan denied your 
request. The Plan says the provider was out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only provided by a network provider.  
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we 
decided that the Plan does not have to pay for the hearing aid provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on 
September 12, 2022. 
 
  You asked the Plan to pay for a determination of refractive state (92015). You say that you were billed a $50 
copayment, but it should only be a $15 copayment. You also say the benefit is a $15 copayment for diagnostic 
services with no limits under the benefit. The Plan denied your request. The Plan says this benefit was 
exhausted on January 13, 2022. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services once per calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover routine eye examinations once per 
calendar year. The record shows that this service was previously provided to you on January 13, 2022. Based 
on this information, we decided that the Plan's rules for coverage of a determination of refractive state (92015) 
have not been met. Therefore, we decided that the Plan does not have to pay for a determination of refractive 
state (92015) provided on September 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), of the abdomen; without 
contrast material (74150). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the follow-up for a complex 
renal cyst usually requires a CT scan or a magnetic resonance imaging (MRI) scan with and without contrast in 
order to characterize the enhancement characteristics of the mass in question. The notes describe stage III 
chronic kidney disease but the creatinine nor the Glomerular filtration rate (GFR) is in the records. The 
requested CT scan of the abdomen would not offer any more information than a surveillance ultrasound. Thus, 
the safety of contrast administration must be addressed by the referring clinician. If there is contraindication to 
contrast, both the MRI and CT scan would be unavailable since each of those may pose a risk to a patient with 
a low GFR.  If contrast is deemed safe to administer, a CT scan of the abdomen with and without contrast using 
renal mass protocol, should be ordered and approved. If contrast enhancement is not possible, a close 
surveillance renal ultrasound would be the procedure of choice in order to assess any change in sonographic 
characteristics or size.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT), of the abdomen; without contrast material (74150).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to provide 18 additional skilled nursing facility days provided from 
June 30, 2022 to July 29, 2022. 
 
You asked the Plan to provide the skilled nursing facility stay. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as you 
have exhausted your maximum benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from 06/16/2022 to 
10/07/2022. The Plan has covered 100 days of SNF care.  
 
 
  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to provide 18 additional skilled nursing facility days provided from June 30, 2022 
to July 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the cataract surgery. You say that equipment in other provider facilities is 
inadequate. 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 
cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 21, 2022, to 
April 22, 2022. 
 You asked the Plan to pay for the home health services as billed. 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 follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, we find that 
the Q code line was not billed with the same revenue code and date of service correctly. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from March 21, 2022, to April 22, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way trips. 
 
You asked the Plan to pre-approve additional one-way trips. You say that you feel you are being denied your 
right to go to church, and grocery shopping. The Plan denied your request. The Plan says extra one-way 
transportation trips cannot be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional one-way trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts (D7953) for tooth #21, #22, 
#23, #24, #25, #26, #27, and #28. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because bone replacement grafts are 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 bone 
replacement grafts (D7953) for tooth #21, #22, #23, #24, #25, #26, #27, and #28.