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

 
We decided that the Plan has to pre-approve extractions of tooth #4, 6, 7, 10, 11, 14, 18, 23, 24, 26, 29, 30, and 31. 
 
You asked the Plan to pre-approve the extractions. You say that the enrollee needs to have these teeth extracted 
to be placed on the liver transplant list. The Plan denied your request. The Plan says that this service is not 
covered by your Plan's benefits. 
 
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. The Plan did not provide the correct Evidence of Coverage (EOC). Without the 
EOC we are unable to determine if the requested extractions are a covered benefit. Therefore, we decided that 
the Plan has to pre-approve extractions of tooth #4, 6, 7, 10, 11, 14, 18, 23, 24, 26, 29, 30, and 31.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that the additional trips 
are medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
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 60 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 20 additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a panoramic x-
ray (D0330) provided on March 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 requested items or services was exhausted on date of service July 6, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 
panoramic x-ray (D0330) provided on March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the record shows the enrollee's needs can be met 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #15 provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that the crown you had put in fell out. 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 12, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth #15 provided by a 
participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hemoglobin, glycosylated (A1C) (83036) provided 
October 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you have attached the medical records for 
review. Kindly process the claim toward payment. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. CPT 83036 is not a Medicare benefit for the diagnosis listed on the claim and is 
done for screening purposes. 
 
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 laboratory services, 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 hemoglobin, glycosylated (A1C) (83036) provided October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment provided on December 27, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oxygen equipment. You say that you needed a bigger tank for your trip. The 
Plan denied your request. The Plan says the equipment was provided out-of-network and was not approved in 
advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the oxygen equipment provided on December 27, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a core build-up for tooth #19 provided by an out-of-
network provider on February 4, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel like this should be covered more. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a core build-up for tooth #19 provided by an 
out-of-network provider on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided from January 17, 2022, to 
January 24, 2022. 
 
You asked the Plan to pay for acupuncture. You say that you called the Plan and they verified that you had 
coverage for acupuncture. The Plan denied your request. The Plan says a licensed acupuncturist is a non-
covered provider type and the provider is not supervised by any physician, physician assistant, nurse 
practitioner or a clinical nurse specialist. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture services provided 
from January 17, 2022, to January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary complete dentures (D5110) and mandibular 
partial dentures (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures broke, and you cannot wait 
to get new ones. 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 requested items or services was exhausted on date of service October 2, 2019. 
Therefore, we decided that the Plan does not have to pre-approve maxillary complete dentures (D5110) and 
mandibular partial dentures (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) provided by a participating 
provider. 
 
You asked the Plan to pre-approve gingival irrigation. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says the requested services are not covered. 
 
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 
gingival irrigation (D4921) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and progressive lenses (V2781) provided 
January 19, 2022. 
 You asked the Plan to pay for the frames and progressive lenses. You say that you would like your glasses to 
be covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
service. 
 
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 one pair of standard lenses and frames every 2 years. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that routine eyewear was 
previously covered on January 29, 2021.  Based on this information, we decided that the Plan's frequency limit 
for coverage of the frames and progressive lenses has been exceeded. Therefore, we decided that the Plan does 
not have to pay for the frames (V2020) and progressive lenses (V2781) provided January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
October 15, 2021, to October 17, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford this 
copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
copayment per day for Inpatient Hospital Care. ($290 per day x 2 days = $580 copayment) 
 
You have been asked to pay a $290 copayment per day for an inpatient hospital stay. An inpatient hospital stay 
falls within the In Network Inpatient Hospital 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 an inpatient hospital stay provided on October 15, 2021, to October 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on March 30, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network, and it 
was determined these services must be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 outpatient mental health services provided on 
March 30, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) and speech therapy 
(ST) services and a transthoracic echocardiogram (TTE) with doppler (ultrasound) provided from April 24, 
2021, to April 26, 2021. 
 
You asked the Plan to waive the copayments for the therapy services and ultrasound. You say that you feel you 
should not have to pay for the services. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 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 $35 
copayment for each physical and speech therapy visit. 
 
Your contract with the Plan also clearly says that you must pay a $160 copayment for radiological diagnostic 
services, including ultrasounds. 
 
You have been asked to pay a $35 copayment for each of the therapy services. The therapy services fall within 
the Outpatient Rehabilitation Services benefit category. You have also been asked to pay a $160 copayment for 
the ultrasound. The ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. The total for the services is $230. 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 physical therapy (PT) and speech therapy (ST) services and a transthoracic echocardiogram (TTE) with 
doppler (ultrasound) provided from April 24, 2021, to April 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visit and diagnostic imaging 
provided on December 6, 2021, and December 16, 2021. 
 
You asked the Plan to waive the copayments for office visit and diagnostic imaging. You say that these charges 
should be covered. The Plan denied your request. The Plan says the copayments applied are correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $105 
copayment for diagnostic imaging and $40 copayment for services obtained from a specialist.  
 You have been asked to pay a total of $200.36 copayment for the office visits and diagnostic imaging. You 
have been asked to pay $40 copayment ($40 x 2 visits) for the office visits and $60.18 copayment ($60.18 x 2 
visits) for the diagnostic imaging which is less than the standard $105 copayment. The diagnostic imaging falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category.  The specialist 
office visits fall within the Physician/Practitioner Services, Including Doctors Office Visits 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 office visit and diagnostic imaging provided on December 
6, 2021, and December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 11, 2022 billed with 
codes 81401, 81479, 81355, 81241, 81240, 81291, 81225, 81226, 81227, 81230, 81231, and 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 11, 2022 billed with codes 81401, 81479, 81355, 81241, 81240, 81291, 81225, 81226, 81227, 81230, 
81231, and 81328.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at home COVID-19 test kits purchased on January 13, 
2022. 
 
You asked the Plan to pay for the at home COVID-19 test kits. You say that these tests are required for 
traveling on a cruise ship. You also say that you submitted a similar request from September 2021, and were 
paid the amount submitted minus the shipping charge. The Plan denied your request. The Plan says Original 
Medicare does not pay for over-the-counter COVID-19 tests, and the Plan does not cover COVID-19 
surveillance testing. The Plan also says that shipping is not medical in nature, and no reimbursement can be 
made for this. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.  
 
We looked at the file and Medicare rules. This testing was required by a cruise line for the purposes of routine 
travel. Based on this information, we decided that Medicare rules for coverage of screening testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the at home COVID-19 test kits 
purchased on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on February 11, 2022, by 
an out-of-network (OON) provider.