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

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on 
October 18, 2022. 
 
  You asked the Plan to pay for a determination of refractive state (92015). You say that you have two cataracts 
that need to be removed but because of your heart and high blood pressure the doctor will not approve the 
operations. The Plan denied your request. The Plan says eye refractions are only covered by your plan if 
performed by a participating Plan vision vendor provider and performed as a routine screening. 
 
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 done during a routine examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that refractive services are not covered under your 
medical benefit Plan. The Plan rules also say that eye refractions are covered during a routine examination. The 
record shows that this service was an eye refraction for a medical diagnosis. Based on this information, we 
decided that the Plan's rules for coverage of a determination of refractive state (92015) have not been met. 
Therefore, we decided that the Plan does not have to pay for a determination of refractive state (92015) 
provided on October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and maxillary partial denture (D2740, D5225) 
provided on July 14, 2022, to August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
and maxillary partial denture (D2740, D5225) provided on July 14, 2022, to August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) for tooth #26 provided on 
June 24, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service should be covered because 
there was a delayed dental statement. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the bone replacement graft is 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 a bone 
replacement graft (D7953) for tooth #26 provided on June 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance image (MRI) of the spine and 
pelvis without contrast (72146). 
 
You asked the Plan to pre-approve an MRI of the spine and pelvis. You say that you disagree with the denial. 
The Plan denied your request. The Plan says there is no mention of thoracic back pain, myelopathy, or an 
intention to order an MRI of the spine. The MRI ordered is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the spine and pelvis. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found a thoracic spine MRI is 
not indicated as there is no evidence of myelopathy of thoracic disc herniation. There is no clinical evidence of 
lumbar disc herniation. There is no documented neurologic deficit. MRI of the thoracic lumbar spine and pelvis 
is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the spine and pelvis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a magnetic resonance image (MRI) of the spine and pelvis without 
contrast (72146).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on July 14, 2021. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
you have submitted additional documents for proof that the transport was medically necessary. 
 The Plan denied your request. The Plan says the ambulance transport was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the transportation via ambulance from the enrollee's doctor's 
office to the home was not medically necessary.  Our physician reviewer found the enrollee did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport. Transport could have been provided by 
other means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complex cystometrogram, electromyography studies 
(EMG), voiding pressure study, and urinalysis provided on June 15, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a complex cystometrogram, EMG, voiding pressure study, and urinalysis. You 
say that the records attached support the services that were provided. The Plan denied your request. The Plan 
says there is no authorization on file for the services 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 a complex cystometrogram, electromyography 
studies (EMG), voiding pressure study, and urinalysis provided on June 15, 2022, by an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computerized tomography (CT) scan on 
October 13, 2022, to October 21, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment per provider, per date of service for complex Radiology (MRI/MRA, CT scans, nuclear cardiology 
studies). Covered services include, but are not limited to MRI/MRA, CT scans, PET scans, nuclear cardiology 
studies, proton beam therapy. The provider billed in the amount of $2,377 and the allowed amount is $116.03. 
The provider also billed in the amount of $2,364 and the allowed amount is $190.38. $116.03 + $190.38 = 
$306.41. This is less than the copayment amount. Therefore, results in the total cost sharing amount of $306.41. 
 
 You have been asked to pay a $306.41 copayment, which is less than the copayment for CT scans. This 
item/service falls 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 computerized tomography (CT) scan on October 13, 2022, 
to October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for clinical crown lengthening of hard tissue (D4249) provided 
on October 5, 2022. 
 
You asked the Plan to pay for clinical crown lengthening of hard tissue (D4249). You say that you were told 
that dental services were covered. You also say you were also told that even if you were told that any services 
were not covered, you could submit it for reimbursement. The Plan denied your request. The Plan says this is 
not covered under your contract under any normal circumstances. 
 
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 clinical 
crown lengthening of hard tissue (D4249) provided on October 5, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for physical therapy provided on December 23, 2021, through June 30, 
2022. 
 
You asked the Plan to pay for physical therapy. You say that the enrollee would like reconsideration because 
the services are medically necessary. The Plan denied your request. The Plan says that physical therapy is not 
medically necessary. 
 
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 records do not show the rendering provider is not eligible to receive 
Medicare payment. Therefore, we decided that the Plan has to pay for physical therapy provided on December 
23, 2021, through June 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on May 25, 
2022, to May 27, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. 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 $175 
copayment for inpatient hospital care. 
 
You have been asked to pay a $175 copayment for inpatient hospital stay. This item/service falls within the 
inpatient hospital care 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. You have been asked to pay $350 ($175 x 2 days) copayment for your inpatient stay. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital stay provided 
on May 25, 2022, to May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the claim should be paid for as it is for an office 
visit. The Plan denied your request. The Plan says there is no authorization on file for the services provided. 
 
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 October 27, 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 dental services on October 3, 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 service 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 the dental 
services on October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture (D5213) provided on November 1, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you were not informed by the provider that the 
service would not be covered if it was provided before five years. 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 19, 2018. 
Therefore, we decided that the Plan does not have to pay for the upper partial denture (D5213) provided on 
November 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are 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 the enrollee does not treat with insulin three or more times per day or use an insulin pump. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth #32 (D7240) and therapeutic 
parenteral drugs (D9612) provided on September 12, 2022. 
 
You asked the Plan to pay for the removal of an impacted tooth and therapeutic drugs. You say that these 
services were medically necessary. The Plan denied your request. The Plan says that the removal of an 
impacted tooth (D7240) and therapeutic parenteral drugs (D9612) are not covered by 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 the 
removal of impacted tooth #32 (D7240) and therapeutic parenteral drugs (D9612) provided on September 12, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) 
sensor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are 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 the enrollee does not treat with 
insulin three or more times per day or use an insulin pump. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone graft (D3428) for tooth number 19 provided on 
September 1, 2022. 
 
You asked the Plan to pay for bone graft (D3428) for tooth number 19. You say that this was to just be a tooth 
extraction. You also say no other service or procedure was explained to your or authorized by you. The Plan 
denied your request. The Plan says this service is not covered under 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 bone graft 
(D3428) for tooth number 19 provided on September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a medical eye examination (92004) and 
ophthalmic diagnostic imaging (92133) provided on September 23, 2022. 
 
You asked the Plan to waive the deductible for a medical eye examination (92004) and ophthalmic diagnostic 
imaging (92133). You say that this was a normal yearly eye examination. You also say that you were not there 
for any specific problem as the examination shows that your vision is very good. 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 $500 deductible which applies to Outpatient physician services 
provided by an ophthalmologist or optometrist for the diagnosis and treatment of diseases and injuries of the 
eye, including diagnosis or treatment for age-related macular degeneration or cataracts.  
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient physician 
services provided by an ophthalmologist or optometrist for the diagnosis and treatment of diseases and injuries 
of the eye, including diagnosis or treatment for age-related macular degeneration or cataracts benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which 
applies to Outpatient physician services provided by an ophthalmologist or optometrist for the diagnosis and 
treatment of diseases and injuries of the eye, including diagnosis or treatment for age-related macular 
degeneration or cataracts. This cost sharing is a contractual obligation that had not been met at the time a 
medical eye examination (92004) and ophthalmic diagnostic imaging (92133) was received on September 23, 
2022. Therefore, we decided that the Plan does not have to waive the deductible for a medical eye examination 
(92004) and ophthalmic diagnostic imaging (92133) provided on September 23, 2022.