Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 Sensor kit. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 Sensor kit. You say that the sensors are needed for the 
patient to monitor their blood glucose levels. You also say that the patient's A1C increased from 9.6% to 
14.7%. The Plan denied your request. The Plan says the enrollee does not require insulin three or more times 
daily. 
 
 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 
the FreeStyle Libre 2 Sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 2 Sensor kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation with limited field 
of view (D0364) provided on December 15, 2022. 
 
You asked the Plan to pay for cone beam CT capture and interpretation with limited field of view. You say that 
this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 cone 
beam CT capture and interpretation with limited field of view (D0364) provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis  adult (D1110) November 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not agree with the denial of the 
requested service. 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 prophylaxis  adult (D1110) but is limited to twice per year. 
  
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered prophylaxis  adult D1110 on February 22, 2022, and June 21, 2022. Therefore, 
these benefits were exhausted as of June 21, 2022. Therefore, we decided that the Plan does not have to pay for 
prophylaxis  adult (D1110) November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on March 24, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that you believe this provider is in-
network. The Plan denied your request. The Plan says this was not authorized. 
 
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 a domiciliary or rest home visit provided on 
March 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 complete denture - maxillary (D5110) provided on January 
4, 2023. 
 
You asked the Plan to pay for dental services. You say that you were told when you signed up for your 
insurance, that dentures would be covered. 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. Complete denture - maxillary 
(D5110) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5110 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for complete denture 
- maxillary (D5110) provided on January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crown, porcelain fused to high noble metal (D6750) 
and pontic-porcelain fused to high noble metal (D6240) provided on November 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted under the same 
claim. 
 
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. Therefore, we decided that the Plan does 
not have to pay for retainer crown, porcelain fused to high noble metal (D6750) and pontic-porcelain fused to 
high noble metal (D6240) provided on November 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77061 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code 77061. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77061 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77061 billed for date of service August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal adjustment (D9952). 
 
You asked the Plan to pre-approve the dental service. You say that this would be a financial hardship for you 
to pay. The Plan denied your request. The Plan says this service is a non-covered benefit of your contractual 
dental insurance 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 an 
occlusal adjustment (D9952).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor supplies provided on August 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for continuous glucose monitor supplies. You say that these items were medically 
necessary. The Plan denied your request. The Plan says these items were not authorized. 
 
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 continuous glucose monitor supplies provided on 
August 20, 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 an office visit provided on July 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this is covered by Original Medicare. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 July 21, 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 eye examination provided on August 9, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the eye examination. You say that the provider has been in-network for many 
years. The Plan denied your request. The Plan says the providers were out-of-network and the enrollee's 
primary care provider did not refer for services. 
 
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 
eye examination. We found no exception that would require the Plan to pay for the eye examination. Therefore, 
we decided that the Plan does not have to pay for the eye examination provided on August 9, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the coverage criteria was not 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 Sensor kit. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 Sensor kit. The Plan denied your request. The Plan 
says the enrollee does not require insulin three or more times daily. 
 
 
 
 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 
the FreeStyle Libre 2 Sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 2 Sensor kit.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each ambulance transportation provided on 
October 30, 2022, to November 03, 2022. 
 
You asked the Plan to waive the copayment for each ambulance transportation. You say that you did not know 
how much you would be charged for this service. 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 $265 
copayment for ambulance services. 
 
You have been asked to pay a $265 copayment for each ambulance transportation. 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. The total amount you owe is $795 ($265 copayment x 3 dates of service = $795). 
Therefore, we decided that the Plan does not have to waive the copayment for each ambulance transportation 
provided on October 30, 2022, to November 03, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided on 
December 20, 2022, to December 21, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital observation. You say that you disagree with 
the 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 $325 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $325 copayment for outpatient hospital observation. This item/service falls 
within the outpatient hospital observation 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 hospital observation provided on December 20, 2022, to December 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on December 13, 2022. 
 
You asked the Plan to pay for a specialist visit. You say that this is supported in the records. 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 a specialist visit 
provided on December 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for inpatient hospital care provided on 
November 22, 2022, to November 23, 2022. 
 
You asked the Plan to waive the cost share for inpatient hospital care. You say that you disagree with the cost 
share. 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. Your 
contract with the Plan says that there is a $850 per stay, after your $1,000 plan deductible which applies to 
inpatient hospital care.  
 
The item or service you asked the Plan to waive the cost share for falls within the inpatient hospital care benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $850 per 
stay, after your $1,000 plan deductible which applies to inpatient hospital care. The total amount you are being 
asked to pay is $766.29 towards your $1,000 deductible. The total amount you are being asked to pay is 
$1,616.29 ($766.29 + $850 = $1,616.29). This cost sharing is a contractual obligation that had not been met at 
the time inpatient hospital care was received on November 22, 2022, to November 23, 2022. Therefore, we decided that the Plan does not have to waive the cost share for inpatient hospital care provided on November 
22, 2022, to November 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on November 
04, 2022. 
 
You asked the Plan to pay for principal care management services. You say that the enrollee does not have a 
choice on which provider they see. 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 principal care 
management services provided on November 04, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter mitral valve repair (TMVR). 
 
You asked the Plan to pre-approve TMVR. 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. 
 
The Plan follows Medicare rules. Medicare rules say that for the treatment of symptomatic moderate-to-severe 
or severe functional mitral regurgitation (MR) when the patient remains symptomatic despite stable doses of 
maximally tolerated guideline-directed medical therapy (GDMT) plus cardiac resynchronization therapy, if 
appropriate, or for the treatment of significant symptomatic degenerative MR when furnished according to a 
Food and Drug Administration (FDA)-approved indication and when certain conditions are met. 
 
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 TMVR. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the eligibility for TMVR includes 
prohibitive risk of surgical repair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMVR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcatheter mitral valve repair (TMVR).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the problem focused limited oral evaluation 
(D0140), periapical first x-ray (D0220) and crown (D2740) provided on November 14, 2022. 
 
You asked the Plan to waive the cost share for the dental services. You say that you are appealing the denial. 
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 50% 
coinsurance for crowns. Additionally, when services are received out-of-network the difference between the 
billed amount and the allowed amount become the enrollees responsibility. 
 You have been asked to $1,048 for the dental services. This item/service falls within the Dental 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 cost share for the problem focused limited oral 
evaluation (D0140), periapical first x-ray (D0220) and crown (D2740) provided on November 14, 2022.