Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (Indomethacin) provided on 
April 29, 2022. 
 
You asked the Plan to pay for the Indomethacin. The Plan denied your request. The Plan says Indomethacin is a 
self-administered medication not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(Indomethacin) provided on April 29, 2022.  
 
Benefits for the Indomethacin may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scaling and root planing-one to three 
teeth per quadrant (D4342), the guided tissue regeneration-resorbable barrier, per site (D4266), the bone 
replacement graft for ridge preservation-per site (D7953), the extraction of an erupted tooth requiring removal 
of bone and/or sectioning of tooth (D7210), and the re-evaluation-limited, problem focused (D0170) provided 
from March 25, 2022, through June 7, 2022. 
 
You asked the Plan to pay more for these dental services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. 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. Additionally, the guided tissue regeneration, bone replacement graft for ridge preservation, and the 
re-evaluation provided are not listed as covered services under your contractual policy. You have exhausted the 
allowable benefit for the periodontal scaling and root planing provided as this service was previously paid for 
on July 18, 2022. The Plan benefit allows for one procedure code every three calendars, per quadrant to be 
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. 
 
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.  
Additionally, a guided tissue regeneration-resorbable barrier, per site, a bone replacement graft for ridge 
preservation-per site, and the re-evaluation provided are services that are not covered under your contractual 
policy. The periodontal scaling and root planing-one to three teeth per quadrant provided is not covered in this 
case as one procedure code per three calendar years, per quadrant is covered by the Plan. The Plan previously 
paid for this dental service on July 8, 2022; therefore, the benefit for this service has been exhausted. 
Therefore, we decided that the Plan does not have to pay more for the periodontal scaling and root planing-one 
to three teeth per quadrant (D4342), the guided tissue regeneration-resorbable barrier, per site (D4266), bone 
replacement graft for ridge preservation-per site (D7953), the extraction of an erupted tooth requiring removal 
of bone and/or sectioning of tooth (D7210), and the re-evaluation-limited, problem focused (D0170) provided 
from March 25, 2022, through June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair accessory, expandable controller 
(E2377), a power wheelchair accessory, harness for upgrade to expandable controller (E2313), a wheelchair 
accessory, manual swingaway, retractable or removable mounting hardware for joystick (E1028) and a seat 
function controller (K0108). 
 
 
 
 
 
 You asked the Plan to pre-approve wheelchair accessories. You say that the requested items are medically 
necessary for the enrollee to facilitate independent ADL's, mobility and activities. The Plan denied your 
request. The Plan says upgraded electronics (electronic connection, expandable controller and harness) cannot 
be covered per Medicare rules. They are necessary when there is a medical need to control power options 
through the joystick. The notes do not show a medical need to control the power options through the joystick. 
The power options can be controlled using their own switches. These switches can be made any size without 
asking for a separate request. They can be made from any material without asking for a separate request. All of 
this can be done without the need to use the joystick to control the power features. The swingaway hardware 
that was requested cannot be covered as the requested already includes swingaway hardware and is unbundled. 
The requested multiple seat function controller is included with the requested controller. This cannot be 
requested separately. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power wheelchair accessory, expandable controller (E2377), a power wheelchair accessory, 
harness for upgrade to expandable controller (E2313), a wheelchair accessory, manual swingaway, retractable 
or removable mounting hardware for joystick (E1028) and a seat function controller (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the caries risk assessment and documentation (D0601) 
provided on April 25, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the caries risk 
assessment and documentation (D0601) provided on April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes E0673, E0666, E0650, and 97760 provided 
on December 14, 2021. 
 
You asked the Plan to pay for procedure codes E0673, E0666, E0650, and 97760. 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 the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure codes E0673, E0666, 
E0650, and 97760 provided on December 14, 2021, have been met. There is no documentation of one or more 
venous ulcer(s) which have failed a 6-month trial of conservative therapy directed by the treating provider. 
Therefore, we decided that the Plan does not have to pay for procedure codes E0673, E0666, E0650, and 97760 
provided on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the items are necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the abdomen/pelvis and chest x-ray provided on April 11, 2022, billed with codes 74177-26 and 71045-26, 
respectively. 
 
You asked the Plan to pay for the imaging interpretation. You say that this must be reimbursed due to medical 
necessity. The Plan denied your request. The Plan says payment has been approved for all codes except for 
74177 and 71045 as these are not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT codes at issue are not supported in the medical record. Specifically, the documentation 
does not contain an imaging report from the billing physician to support these codes. Based on this information, 
we decided that Medicare rules for coverage of the imaging interpretation have not been met. Therefore, we 
decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the 
abdomen/pelvis and chest x-ray provided on April 11, 2022, billed with codes 74177-26 and 71045-26, 
respectively.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) of the 
abdomen and pelvis (74177) provided on May 3, 2022. 
 
You asked the Plan to waive the copayment for the CT of the abdomen and pelvis. You say that when you 
called for a referral, you were advised that the service would be covered in full. The Plan denied your request. 
The Plan says the copayment amount the enrollee is being charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $325 copayment for other Medicare-covered diagnostic radiology services under the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category.  
 
 
  The enrollee has been asked to pay a $325 copayment for the CT of the abdomen and pelvis. The CT of the 
abdomen and pelvis falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 computed tomography (CT) 
of the abdomen and pelvis (74177) provided on May 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the continuous glucose monitor 
is medically necessary. The Plan denied your request. The Plan says 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. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transportation (A0130) and non-
emergency transportation case worker or social worker (A0160) provided on March 2, 2022. 
 
You asked the Plan to pay for the wheelchair van transportation and case worker or social worker. You say that 
you would like this claim to be reprocessed for payment to show the enrollee is responsible for the full charges. 
The Plan denied your request. The Plan says these services are not allowed, and the enrollee is not liable for the 
denied charges. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
 
 The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the wheelchair van transportation (A0130) and non-emergency 
transportation case worker or social worker (A0160) provided on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says these compression stockings are not covered 
as they are not considered primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation provided on April 14, 2022. 
 
You asked the Plan to pay for a dental consultation. The Plan denied your request. The Plan says a dental 
consultation is not a covered benefit. 
 
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 a dental 
consultation (code D9310) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on February 23, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under the 
enrollee's contractual 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation (D0180) provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 22, 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 22, 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 the office visit provided by an out-of-network provider 
provided on April 13, 2022. 
 
You asked the Plan to pay for the office visit. You say that you went to the same doctor, but they had you see 
someone else. You say that you weren't aware of the change and cannot afford to pay. The Plan denied your 
request. The Plan says you must receive care from a network provider. 
 
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 office visit provided by an out-of-network 
provider provided on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate or equal lens (V2784), progressive lens 
(V2781) and tint, any color, solid, gradient (V2745) provided on May 17, 2022. 
 
You asked the Plan to pay for polycarbonate or equal lens (V2784), progressive lens (V2781) and tint, any 
color, solid, gradient (V2745). You say that this was your first eye exam. You also say that it was made quite 
clear to you when you purchased this health plan that issues related to the eyes would be covered. The Plan 
denied your request. The Plan says the denied (DN) enhancements or services are not covered benefits, but may 
be purchased by the member at an additional cost. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover these eyewear features. 
 
We looked at the file and the Plan's rules. The Plan says that these services (V2784, V2781, V2745) are not 
covered through the allowance but may be purchased at an additional cost. Based on this information, we 
decided that the Plan's rules for coverage of polycarbonate or equal lens (V2784), progressive lens (V2781) and 
tint, any color, solid, gradient (V2745) have been met. Therefore, we decided that the Plan does not have to pay 
for polycarbonate or equal lens (V2784), progressive lens (V2781) and tint, any color, solid, gradient (V2745) 
provided on May 17, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayments for eye procedure follow ups on April 4, 2022, and 
April 11, 2022. We decided that the Plan does not have to waive the copayments for an eye procedure provided 
on March 30, 2022.  
 
You asked the Plan to waive the copayments for three eye procedures. You say that you could understand one 
$250 copayment, but not the follow up visits. The Plan says that the $250 copayment applied on March 30, 
2022, is upheld. 
 We decided that the Plan has to waive the copayments for eye procedure follow ups on April 4, 2022, and 
April 11, 2022..  
 
The Plan follows Medicare rules. The Plan did not receive medical records for dates April 4, 2022, and April 
11, 2022. Therefore, they waived the two extra $250 copayments ($250 x 2 = $500). Therefore, we decided that 
the Plan has to waive the copayments for eye procedure follow ups on April 4, 2022, and April 11, 2022..  
 
We also decided that the Plan does not have to waive the copayments for an eye procedure provided on 
March 30, 2022. 
 
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 an eye procedure provided on March 30, 2022. Therefore, we decided that the Plan does not 
have to waive the copayments for an eye procedure provided on March 30, 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.