Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on May 09, 2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the assisted living facility is 
responsible for obtaining authorization. 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 domiciliary or rest 
home visit provided on May 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 14, 2022. 
 
You asked the Plan to pay for the office visit. You say that the enrollee has a Louisiana policy and this should 
be paid. 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 September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on September 23, 2022. 
 
You asked the Plan to pay for the vision services. You say that you were informed that you would be 
reimbursed half of the cost. 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 vision services 
provided on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology procedures provided on August 24, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for radiology procedures. You say that the records attached support the services 
rendered. The Plan denied your request. The Plan says there was no authorization obtained prior to the services 
being rendered. 
 
 
 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 radiology procedures provided on August 24, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advanced lens package provided from June 2, 2021, to 
June 26, 2021. 
 
You asked the Plan to pay for the advanced lens package. You say that you contacted the Plan prior to services 
being rendered and were told that the lenses would be taking care of. The Plan denied your request. The Plan 
says they contacted the provider and were advised that the bill was not submitted to the Plan, because you had 
been notified prior to the date of service that this type of lens would not be covered by your insurance. The Plan also say that you were notified by the provider and signed a waiver at the provider's office with the 
understanding that the lens would be your liability. 
 
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. This service is excluded from your benefit package. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover lenses. However, the advanced lens 
package is excluded from this benefit. The record shows you signed a waiver stating you understood and were 
financially responsible for this lens package. Based on this information, we decided that the Plan's rules for 
coverage of the advanced lens package have not been met. Therefore, we decided that the Plan does not have to 
pay for the advanced lens package provided from June 2, 2021, to June 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontic maintenance (D4910) and a periodic oral 
evaluation (D0120) provided on October 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the third annual cleaning may have 
been paid in the past year or two. You also say you feel this should be paid. 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 June 7, 2022. Therefore, 
we decided that the Plan does not have to pay for periodontic maintenance (D4910) and a periodic oral 
evaluation (D0120) provided on October 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 18, 2022. 
 
You asked the Plan to pay for lab testing. 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 lab testing provided on 
April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), bifocal lenses (V2200), anti-reflective 
coating (V2750), and ultraviolet lenses (V2755) provided on January 3, 2022. 
 
You asked the Plan to pay for frames (V2020), bifocal lenses (V2200), anti-reflective coating (V2750), and 
ultraviolet lenses (V2755). You say that the Explanation of Benefits says that you are not responsible for 
paying the billed amount. You also say that you are not legally obligated to pay the tax/surcharge. The Plan 
denied your request. The Plan says they made payment according to the Medicare allowable rate. 
 
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 when the Plan will reimburse up to $115 every year for non-Medicare 
covered prescription eyewear. 
 
We looked at the file and the Plan's rules. The rules say the Plan will reimburse up to $115 every year for non-
Medicare covered prescription eyewear. The Plan rules also say you are responsible for any amount above the 
eyewear coverage limit. The record shows this benefit was exhausted on January 3, 2022. Based on this 
information, we decided that the Plan's rules for coverage of frames (V2020), bifocal lenses (V2200), anti-
reflective coating (V2750), and ultraviolet lenses (V2755) have not been met. Therefore, we decided that the 
Plan does not have to pay for frames (V2020), bifocal lenses (V2200), anti-reflective coating (V2750), and 
ultraviolet lenses (V2755) provided on January 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment and coinsurance for cataract eye surgery and a 
dexamethasone injection provided on February 7, 2022. 
 
You asked the Plan to reduce the copayment and coinsurance for the cataract surgery and injection. You say 
that you were only informed of the $200 copayment for the cataract surgery. 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 $200 
copayment for outpatient surgery or procedures at an ambulatory surgical center and a 20% coinsurance for 
Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a $200 copayment for the cataract surgery. This item/service falls within the 
outpatient surgery or procedures at an ambulatory surgical center benefit category. You have also been asked to 
pay $99.26 for the injection, which is 20% of the Medicare allowed amount ($496.32 allowed x 20% = $99.26). 
This item/service falls within the Medicare Part B prescription drugs 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 reduce the copayment and coinsurance for cataract eye surgery and a dexamethasone injection 
provided on February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
September 13, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this 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 $25 
copayment for specialist office visits. 
 
You have been asked to pay a $25 copayment for specialist office visit. This item/service falls within the 
specialist 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 specialist 
office visit provided on September 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia (D9223, D9222) provided 
on August 5, 2022. 
 
You asked the Plan to pay for the deep sedation/general anesthesia. 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 pay for deep 
sedation/general anesthesia (D9223, D9222) provided on August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional image 
(D0230) x2, panoramic radiographic image (D0330) and prophylaxis  adult (D1110) provided on August 8, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the provider submitted your claims incorrectly; 
therefore, the services billed should be paid for by insurance. 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 D0150, D0220, D0230, D0330 and D1110 but you have an annual maximum of $1,500. After the 
annual maximum is exhausted, any remaining charges are your responsibility. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit of $1,500 annual maximum was exhausted on date of service August 10, 2022. Therefore, 
we decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150), intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional image 
(D0230) x2, panoramic radiographic image (D0330) and prophylaxis  adult (D1110) provided on August 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5120 
and D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve these 
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 18, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5120 
and D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) for tooth #14 provided on 
September 13, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are not satisfied with the decision and are 
appealing the denied payment. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the pulp vitality tests 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 pay for the pulp 
vitality tests (D0460) for tooth #14 provided on September 13, 2022.
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 26, 2022. 
 
You asked the Plan to pay for the oral evaluation. You say that you found a new dentist and had an annual 
cleaning and checkup. You say you feel this should be covered because you had to find a new dentist that 
would accept your insurance, and this caused a lapse in care. 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 March 4, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on September 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Gelsyn-3 injection provided on April 
15, 2022. 
 
You asked the Plan to waive the coinsurance for the Gelsyn-3 injection. You say that you do not agree with the 
coinsurance. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the Gelsyn-3 injection. This item/service falls within the 
Medicare Part B prescription drugs 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 Gelsyn-3 injection provided on April 15, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on July 14, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you believe the copayment 
should be $200 not $300. 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 $300 
copayment for outpatient hospital services. 
 
You have been asked to pay a $300 copayment for outpatient surgery. This item/service falls within the 
outpatient hospital 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 outpatient 
surgery provided on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body; endosteal implant 
(D6010) Tooth #13, 14, custom fabricated abutment  includes placement (D6057) Tooth #13, 14, abutment 
supported porcelain/ceramic crown (D6058) Tooth #13, 14 and sinus augmentation via a vertical approach 
(D7952). 
 
You asked the Plan to pre-approve dental services. You say that you are requesting the health plan to raise your 
benefits. The Plan denied your request. The Plan says this service is not covered under your 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. Surgical placement of implant 
body; endosteal implant (D6010) Tooth #13, 14, custom fabricated abutment  includes placement (D6057) 
Tooth #13, 14, abutment supported porcelain/ceramic crown (D6058) Tooth #13, 14, and sinus augmentation 
via a vertical approach (D7952). 
 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 
surgical placement of implant body; endosteal implant (D6010) Tooth #13, 14, custom fabricated abutment  
includes placement (D6057) Tooth #13, 14, abutment supported porcelain/ceramic crown (D6058) Tooth #13, 
14 and sinus augmentation via a vertical approach (D7952).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the requested CGM and supplies are 
medically necessary. The Plan denied your request. The Plan says that the coverage criteria has not been 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 and does not require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic CGM and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulp vitality tests. 
 
You asked the Plan to pre-approve the dental services. You say that this service is required for proper 
treatment. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
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 pulp 
vitality tests.