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

 
We decided that the Plan does not have to provide additional payment for the frames (V2020), progressive lens 
(V2781), tint, photochromatic (V2744), anti-reflective coating (V2750), and vision item or service, 
miscellaneous (V2799) provided December 3, 2021. 
 
You asked the Plan to provide additional payment for the frames, progressive lenses with photochromatic tint 
and anti-reflective coating and miscellaneous vision item or service. You say that you would like these services 
covered. The Plan denied your request. The Plan says you have already received the maximum amount of 
coverage for routine vision services. 
 
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 up to $200 every year. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that the $200 benefit has 
been applied to your eyewear.  Therefore, we decided that the Plan does not have to provide additional 
payment for the frames (V2020), progressive lens (V2781), tint, photochromatic (V2744), anti-reflective 
coating (V2750), and vision item or service, miscellaneous (V2799) provided December 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 2, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that as a tribal organization, you have the right to 
recover outside of a contract for any services you provide to the Plan's members. The Plan denied your request. 
The Plan says no prior authorization was obtained. 
 
 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on November 2, 2021, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on July 26, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The gene panel was billed with multiple codes. If a single procedure is 
performed, only one code with one unit of service may be reported for the procedure. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Tempus gene panel provided on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve a complete upper denture. You say that you lost your previous dentures and 
need new ones. The Plan denied your request. The Plan says this service will exceed the frequency limit for 
dentures. 
 
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. The Plan covers a complete 
upper denture once every five plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper 
denture was previously covered on May 21, 2019.  Based on this information, we decided that the Plan's 
frequency limit for coverage of a complete upper denture will be exceeded with the requested service. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 26, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says place of service 81 
is not applicable. 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab testing services provided on July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for High frequency chest wall oscillation 
system provided on January 4, 2021 to November 4, 2021. 
 
You asked the Plan to waive the coinsurance for High frequency chest wall oscillation system. You say that 
you shouldn't have to pay for this. The Plan denied your request. The Plan says the cost share applied is 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 20% 
coinsurance for High frequency chest wall oscillation system. The allowed amount of the durable medical 
equipment (DME) is $8,761.50, resulting in a coinsurance amount of $1,752.3. 
 
You have been asked to pay 20% coinsurance for High frequency chest wall oscillation system. High frequency 
chest wall oscillation system falls within the Durable medical equipment (DME) 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 High frequency chest wall oscillation system 
provided on January 4, 2021 to November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic procedure and testing services 
provided on December 9, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic procedure and testing services. You say that you 
are requesting for the Plan to waive the copayment due to the fact you have never received a bill until you 
received a pre-collection letter. The Plan denied your request. The Plan says you were 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 $50 
copayment for Medicare-covered blood services for outpatient diagnostic tests and therapeutic services and 
supplies.   
You have been asked to pay a $50 copayment for a diagnostic procedure and testing services. A diagnostic 
procedure and testing services fall within the outpatient diagnostic tests and therapeutic services and 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 copayment for a diagnostic procedure and 
testing services provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for wound care provided by a network 
facility on September 27, 2021, to December 13, 2021. 
 
You asked the Plan to reduce the copayments for the wound care. You say that your wounds were treated, and 
you were charged for outpatient surgery. You say there was no surgery being done. The Plan denied your 
request. The Plan says you have been asked to pay 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 $150 
copayment for each in-network Medicare-covered outpatient surgery or procedure at an outpatient hospital 
facility or ambulatory surgical center.  
 You have been asked to pay a $150 copayment for the wound care on each date of service. The wound care 
falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. The record shows that wound care is considered a surgical service.  
 
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 copayments for wound care provided by a network facility on September 
27, 2021, to December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided by a contracted 
provider on November 21, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that this provider should not be paid 
for his services because he is not the enrollee's PCP. The Plan denied your request. The Plan says you have 
been asked to pay 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $15 copayment for each Medicare-covered visit with a primary care physician (PCP).  
 
 The enrollee has been asked to pay a $15 copayment for the office visit. The office visit falls within the 
Physician/Physician services, including doctors office visits benefit category. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the office visit provided by a contracted provider on November 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided by a participating 
provider on February 22, 2022. 
 
You asked the Plan to pay for oral hygiene instructions. You say that you feel like this should be covered 
because it was medically necessary. The Plan denied your request. The Plan says the dental services provided 
are not covered 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 oral 
hygiene instructions (D1330) provided by a participating provider on February 22, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituximab. 
 
You asked the Plan to pre-approve Rituximab. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Rituximab. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the plans requested drugs are equally 
eficacious and are not likely to be less effective and/or likely to have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituximab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Rituximab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), and 
root canal (D3330) provided on February 3, 2022. 
 
You asked the Plan to pay the in network rate for the oral evaluation and root canal. You say that you needed to 
have a dental exam before you could have surgery. You say that your dentist referred you to an endodontist for 
a root canal. You also say that you assumed since your dentist was in network that they would refer you to an 
in network endodontist. The Plan denied your request. The Plan says the services were paid according to the 
plan benefits. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation and root 
canal are not among those covered under this benefit, regardless of the provider's network status. Therefore, we 
decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), and root 
canal (D3330) provided on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture - resin base (including, 
retentive/clasping materials, rests, and teeth) (D5212) provided January 13, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the lower partial denture. You say that this is a continuation of services provided 
in 2021. The Plan denied your request. The Plan says this service is not covered when provided OON. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the lower 
partial denture when the services are provided in-network. 
 
We looked at the file and Medicare rules. In this case the dentures were provided OON. Based on this 
information, we decided that the Plan's rules for coverage of the lower partial denture have not been met. 
Therefore, we decided that the Plan does not have to pay for the mandibular partial denture - resin base 
(including, retentive/clasping materials, rests, and teeth) (D5212) provided January 13, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Office Visit services provided on November 24, 2021 to 
January 5, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Office Visit services. You say that you would like to appeal the denial of the 
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 Office Visit services provided on November 24, 
2021 to January 5, 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 retreatment of a previous root canal therapy (D3347) 
provided on October 4, 2021. 
 
You asked the Plan to pay for the retreatment of a previous root canal therapy. You say that you were not 
aware that the Plan was not going to cover this procedure. You also feel that you should not have to pay this 
bill because you were under the impression that it would be covered by your insurance. The Plan denied your 
request. The Plan says this service is not covered under the Plan. The Plan also says that there is no record of 
you contacting the Plan prior to this date of service to inquire if this service was covered under your policy. 
 
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 
retreatment of a previous root canal therapy (D3347) provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on January 18, 2022. 
 
You asked the Plan to pay for the consultation. You say that the consultation was provided by the dentist who 
would be providing the surgery to excise the presumed cyst or to perform other surgery or treatment as 
required. 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 Plan's 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 
consultation (D9310) provided on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
November 8, 2021, to December 2, 2021. 
 
You asked the Plan to pay for dental services. You say that you were never notified that this dentist was out-of-
network. The Plan denied your request. The Plan says services provided by an out-of-network provider are not 
covered 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. The Plan covers covered 
dental services when the services are provided in-network.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on November 8, 2021, to December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on October 22, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. 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 Domiciliary services provided on October 22, 
2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) provided on January 3, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the comprehensive oral 
evaluations were for two different doctors at two different facilities. You also say that this procedure was 
needed to start the process for our dentures. The Plan denied your request. The Plan says that this service 
exceeds the frequency limitation in your benefit plan. 
 
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 a copy of the applicable 2022 Evidence of Coverage 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the comprehensive oral evaluation (D0150) provided on January 3, 2022.  
 
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.