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

 
We decided that the Plan does not have to pre-approve a bone replacement graft and guided tissue regeneration 
(D7953, D4266). 
 
You asked the Plan to pre-approve the dental services. 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 they do 
not fall within your dental benefits. 
 
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 a 
bone replacement graft and guided tissue regeneration (D7953, D4266).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on September 08, 2022, to November 
03, 2022. 
 
You asked the Plan to pay for acupuncture. 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 acupuncture provided on 
September 08, 2022, to November 03, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the cervical and vaginal cancer screening (G0145) provided on January 
12, 2023. 
 
You asked the Plan to pay for the cervical and vaginal cancer screening. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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. To determine if there is evidence based on the enrollee's medical history or other 
findings that she has had an examination that indicated the presence of cervical or vaginal cancer or other 
abnormalities during any of the preceding 3 years, medical records should have been requested for review. The 
Plan has not determined if the enrollee met this criterion and have not substantiated their reasoning for the 
denial of payment. Therefore, we decided that the Plan has to pay for the cervical and vaginal cancer screening 
(G0145) provided on January 12, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the MRI shows spinal stenosis and spondylolysis at L5. The cause of the 
enrollee's back pain is unclear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
August 02, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were not seen this 
day. 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 specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
specialist physician/practitioner services 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. The records show you were seen by a specialist on August 2, 2022. 
Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit 
provided on August 02, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on November 29, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you should 
not be held liable for the CT scan copayment because it was ordered out of necessity. 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 $250 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $250 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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. The total you owe is $174.35, which is less than the standard $250 copayment 
for a CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on November 29, 2022.
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 October 22, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you lost 
consciousness for a moment or two and while unconscious, someone called for an ambulance. You also say 
that you were checked by the ambulance personnel and you felt everything seemed normal so you denied the 
transport. 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 October 22, 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 October 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on January 04, 
2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were told that office visit 
would be fully covered. 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 $30 
copayment for out-of-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for the office visit. This item/service falls within the out-of-
network 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 copayment for the office visit provided on January 04, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
September 17, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this was an emergency 
and you should not have a copayment. 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 $280 
copayment for ambulance services. 
 
You have been asked to pay a $280 copayment for the ambulance services. This item/service falls within the 
ambulance services 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 ambulance 
services provided on September 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation therapy provided on August 01, 2022. 
 
You asked the Plan to pay for radiation therapy. 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 radiation therapy 
provided on August 01, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
December 26, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that these charges should be 
covered. 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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for the ambulance services. This item/service falls within the ambulance services 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 ambulance 
services provided on December 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulp vitality test (D0460), unspecified endodontic procedure 
(D3999), and a surgical procedure for isolation of tooth with rubber dam (D3999) provided on December 19, 
2022. 
 
You asked the Plan to pay for pulp vitality test, unspecified endodontic procedure, and a surgical procedure for 
isolation of teeth. 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 pay for pulp 
vitality test (D0460), unspecified endodontic procedure (D3999), and a surgical procedure for isolation of tooth 
with rubber dam (D3999) provided on December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), and 
prophylaxis - adult (D1110) provided on September 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that your last cleaning wasnt covered on September 
26, 2022 and the provider sent in a bill not explaining the problem about any insurance problems. The Plan 
denied your request. The Plan says your benefit for the periodic oral evaluation - established patient, and 
prophylaxis - adult 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 periodic oral evaluation - established patient, and prophylaxis - adult was exhausted on 
dates of service February 15, 2022, and May 17, 2022. Therefore, we decided that the Plan does not have to 
pay for a periodic oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided on 
September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a pontic (D6240) and an abutment supported crown 
(D6058) for tooth #19, #20, and #21 provided by an out-of-network provider on August 10, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the work has not been completed and the 
provider also billed your other insurance company. 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. Also, the proper cost share was applied to the dental 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. 
 Documentation shows the Plan did not charge an 80% coinsurance for the dental services and they charged a 
40% coinsurance which is less than what the contract states. For the pontic the total amount billed was $1,870 
and the total amount allowed was $555.42 leaving a difference of $1,314.58 ($1,870 billed - $555.42 allowed). 
The total coinsurance amount for the pontic was $222.16 ($555.42 allowed x 40% coinsurance). For the crown 
for tooth #19 the total amount billed was $2,975 and the total amount allowed was $645.99 leaving a difference 
of $2,329.01 ($2,975 billed - $645.99 allowed). The total coinsurance amount for the crown was $258.39 
($645.99 allowed x 40% coinsurance). For the crown for tooth #21 the total amount billed was $2,975 and the 
total amount allowed was $645.99 leaving a difference of $2,329.01 ($2,975 billed - $645.99 allowed). The 
total coinsurance amount for the crown was $258.39 ($645.99 allowed x 40% coinsurance). The total 
difference amount was $5,972.60 ($1,314.58 difference + $2,39.01 difference + $2,329.01 difference). The 
total coinsurance amount was $738.94 ($222.16 coinsurance + $258.39 coinsurance + $258.39 coinsurance). 
 
You have been asked to pay a coinsurance and 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 pontic (D6240) and an abutment 
supported crown (D6058) for tooth #19, #20, and #21 provided by an out-of-network provider on August 10, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve labial veneers (D2962) for tooth #8 and #9. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary because you are grinding your teeth. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because veneers 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 
labial veneers (D2962) for tooth #8 and #9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as you do not 
meet the clinical requirements to 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 CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and 
supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cala Trio nerve stimulator device (K1018 and K1019) 
provided on November 15, 2022. 
 
You asked the Plan to pay for the Cala Trio nerve stimulator device. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that electrical stimulators to treat motor function 
disorders are not covered. The Cala Trio device is an electrical stimulator that was provided to the member for 
the sole purpose of treating essential tremor. Essential tremor is a motor function disorder. We looked at the 
file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Cala Trio nerve stimulator device have not been met. Therefore, we decided that the Plan does not have to pay for 
the Cala Trio nerve stimulator device (K1018 and K1019) provided on November 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the Dexcom G6 CGM. You say that the items should be covered as you 
disagree with the denial, and they are necessary. The Plan denied your request. The Plan says only the 
FreeStyle Libre brand products listed in the EOC are covered. 
 
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Dexcom G6 CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next test trips. 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that you are requesting the test strips 
for the enrollee. The Plan denied your request. The Plan says only the preferred brand products are covered. 
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, only preferred brands for the blood glucose 
test strips are covered. Therefore, we decided that the Plan does not have to pre-approve Contour Next test 
trips.