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

 
We decided that the Plan does not have to waive the deductible for the contact lens fitting, the medical eye 
exam, the computerized corneal topography, and the refraction on July 27, 2022. The Plan does not have to pay 
for the contact lens provided on August 16, 2022. 
 
You asked the Plan to waive the deductible for the contact lens fitting, the medical eye exam, the computerized 
corneal topography, the refraction, and the contact lens. You say that this was your routine eye exam, and it 
was inappropriate for the claims to apply to your 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. Your 
contract with the Plan says that there is a $400 deductible which applies to the contact lens fitting, the medical 
eye exam, and the computerized corneal topography.  
 
The contact lens fitting, the medical eye exam, the computerized corneal topography, and the refraction you 
asked the Plan to waive the deductible for falls within the vision services and outpatient diagnostic tests and 
therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $400 deductible which applies to the contact lens fitting, the medical eye exam, 
and the computerized corneal topography. Please note, the services were medical in nature. Also, the Plan 
decided to cover the refraction and applied the refraction to the deductible. This cost sharing is a contractual 
obligation that had not been met at the time the contact lens fitting, the medical eye exam, the computerized 
corneal topography, and the refraction was received on July 27, 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 does not cover contact lens. 
 
We looked at the file and the Plan's rules. Specifically, the contact lens is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of the contact lens have not been met.  
 
Therefore, we decided that the Plan does not have to waive the deductible for the contact lens fitting, the 
medical eye exam, the computerized corneal topography, the refraction, and to pay for the contact lens 
provided on July 27, 2022, to August 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. The Plan denied your request. The Plan says 
this request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is not medically reasonable and necessary for the enrollee. Our 
physician reviewer found no plain films have been done. The enrollee's neurological exam was normal. Our 
reviewer also found that there is no red flag to mandate an MRI without first trying conservative management, 
including a 6-week trial of physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 1, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you called 
911 after experiencing some chest pain. You also say that when the emergency medical service arrived you 
refused the transport because you were no longer in pain. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 1, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the durable medical equipment (DME) 
provided from September 2, 2022, to December 13, 2022. 
 
You asked the Plan to waive the coinsurance for the DME. You say that you were told that you would not be 
responsible for the DME cost share. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network durable medical equipment and related supplies.  
 
 
 
 
 
 You have been asked to pay 20% coinsurance for the DME provided from September 2, 2022, to December 13, 
2022. 
Date of 
Service 
Code Allowed 
Amount 
20% 
Coinsurance 
09/02/2022 A6021 $84.00 $16.80 
09/02/2022 A6446 $6.56 $1.31 
09/02/2022 A4452 $16.00 $3.20 
09/02/2022 A6207 $14.66 $2.93 
09/26/2022 A6021 $84.00 $16.80 
09/26/2022 A6446 $6.56 $1.31 
09/26/2022 A4452 $16.00 $3.20 
09/26/2022 A6207 $14.66 $2.93 
10/11/2022 A6447 $17.00 $3.40 
10/26/2022 A4452 $16.00 $3.20 
10/26/2022 A6207 $14.66 $2.93 
10/26/2022 A6021 $ 126.00 $25.20 
10/26/2022 A6446 $10.25 $2.05 
11/21/2022 A6207 $14.66 $2.93 
11/21/2022 A6021 $ 126.00 $25.20 
11/21/2022 A6446 $10.25 $2.05 
12/13/2022 A6021 $126.00 $25.20 
12/13/2022 A6207 $14.66 $2.93 
 
These items/services falls within the in-network durable medical equipment and related supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the durable medical equipment (DME) 
provided from September 2, 2022, to December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper and lower dentures (D5120 and D5110). 
 
You asked the Plan to pre-approve complete upper and lower dentures. You say that this should be covered. 
The Plan denied your request. The Plan says this is 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
complete upper and lower dentures (D5120 and D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you need the machine to help keep track of your low 
blood sugar level. You also say that you no longer have feeling in your fingers. 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 the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on December 07, 2022. 
 
You asked the Plan to pay for a chiropractic visit. You say that you were not aware this provider was out-of-
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 a chiropractic visit 
provided on December 07, 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 need therapy because you are unable to walk. 
The Plan denied your request. The Plan says an IRF admission is not medically necessary, and your needs can 
be provided in other settings. 
 
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 meet criteria for admission to an acute inpatient rehabilitation facility. 
The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. You can receive further services at a 
lower level of care. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve D6011 (implant), D6065 (implant), D5820 (interim 
partial denture, maxillary), D6010 (implant), and D0366 (cone beam CT scan). 
 
You asked the Plan to pre-approve implants, interim partial denture, and a cone beam CT scan. You say that 
these should be covered. The Plan denied your request. The Plan says these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
D6011 (implant), D6065 (implant), D5820 (interim partial denture, maxillary), D6010 (implant), and D0366 
(cone beam CT scan).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection of substance into lower spine canal using imaging 
guidance provided on August 23, 2022. 
 
You asked the Plan to pay for injection of substance into lower spine canal using imaging guidance. You say 
that you are appealing with supporting records. 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 injection of substance 
into lower spine canal using imaging guidance provided on August 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on July 21, 2022, 
to July 26, 2022. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an outpatient mental 
health visit provided on July 21, 2022, to July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 30, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. 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 office visit provided on 
September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occlusal guard  soft appliance, full arch (D9945). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting that your insurance will 
approve the requested item. 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. This benefit includes the 
requested occlusal guard  soft appliance, full arch (D9945) but is limited to once per 24 months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received a covered D9945 on January 27, 2022. Therefore, your benefits was exhausted on date of 
service January 27, 2022. Therefore, we decided that the Plan does not have to pre-approve occlusal guard  
soft appliance, full arch (D9945).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the psychiatry office visits provided on 
October 31, 2022, and November 14, 2022. 
 
You asked the Plan to waive the copayments for the office visits. You say that you only had a $10 copayment 
on previous dates. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each Medicare-covered psychiatry individual session.  
 
You have been asked to pay a $40 copayment for each office visit. You have been asked to pay a total of $80 
($40 copayment per visit x 2 visits = $80). This item/service falls within the outpatient mental health 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 copayments for the psychiatry office visits 
provided on October 31, 2022, and November 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
September 03, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted to 
the hospital and should have the emergency room visit copay waived. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for the emergency room 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 visit 
provided on September 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urgent care office visit provided on January 12, 2023. 
 
You asked the Plan to pay for urgent care office visit. You say that this visit was an urgent care visit and should 
not require not require a referral. 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 urgent care office visit 
provided on January 12, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan said the request cannot be approved because there are no 
results of an x-ray taken after their symptoms started or changed that show a need for further imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the service 
is medically necessary. Our physician reviewer found the enrollee has a congenital condition with a tethered 
low-lying spinal cord. The enrollee has bilateral hip flexor weakness, and his left hip pain is new. The last MRI 
on record was on July 17, 2021, and a plain film would offer no useful information. The request for an MRI of 
the lumbar spine for evaluation prior to injection therapy should be approved. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI have been met. Therefore, we decided that the Plan has to pre-approve a 
magnetic resonance imaging (MRI).  
 
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 a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that you are appealing the denied 
CGM with medical records. The Plan denied your request. The Plan says the Medicare criteria was not 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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (CGM) and related supplies.