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

 
We decided that the Plan does not have to pay more for  immediate denture - mandibular (D5140) x2 and 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7140) x30 provided on June 22, 2022. 
 
You asked the Plan to pay more for  the dental services. You say that you had a hard time finding a provider 
who accepted your insurance, and you were told in-network and out-of-network providers would be covered. 
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. 
 
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. 
Therefore, we decided that the Plan does not have to pay more for  immediate denture - mandibular (D5140) x2 
and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7140) x30 provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve dental services. You say that you want the plan to cover the requested 
services. 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. Maxillary partial denture 
(D5213) is not covered under the Plans dental benefits. 
 
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 
maxillary partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the reports attached support the services provided. The 
Plan denied your request. The Plan says there is no referral or prior 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 July 18, 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 crown - porcelain/ceramic (D2740) Tooth #29 provided on 
June 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want these services covered. 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 crown - porcelain/ceramic (D2740) Tooth 
#29 is 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 crown - porcelain/ceramic (D2740) Tooth #29 provided on June 27, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that acute inpatient rehabilitation is medically necessary. 
The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about 
the enrollee's condition they do not meet all the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows active comorbidities however there are no specified 
complex functional impairments.  The complexity of the enrollee's documented nursing, medical and rehabilitation needs would not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a walker received on June 2, 2022. 
 
You asked the Plan to pay for the services. You say that your provider recommended a walker for assistance. 
The Plan denied your request. The Plan says that there was no authorization on file for these services. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the services by a contract provider. The file does not show that the Plan provided notice 
that the services would not be covered. Under Medicare rules, this means the services is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for a walker received on June 2, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 10, 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 your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 01, 2021. Therefore, 
we decided that the Plan does not have to pay for the dental services on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services provided on August 21, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for portable x-ray services. You say that the services were ordered as STAT and you 
did not want to delay the testing. The Plan denied your request. The Plan says an authorization was not 
obtained prior to services being rendered. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for portable x-ray services provided on August 21, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for leuprolide acetate suspension provided on June 29, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for leuprolide acetate suspension. You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for 
more information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an 
out-of-network provider (a provider who is not part of our plans network) will not be 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 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 leuprolide acetate suspension provided on June 29, 
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 hospital outpatient clinic visit (G0463) and measurement 
of blood oxygen level (94760) provided on June 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that the services should be covered. The Plan 
denied your request. The Plan says prior authorization was not 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 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. Therefore, we 
decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) and measurement of 
blood oxygen level (94760) provided on June 7, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient surgery provided on July 25, 
2022. 
 
You asked the Plan to waive the deductible for outpatient surgery. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $750 
deductible for section 1.2 What is your plan deductible? 
 
You have been asked to pay a $750 deductible for outpatient surgery. You are being asked to pay $32.41 
towards your $750 deductible. This item/service falls within the section 1.2 What is your plan deductible? 
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 deductible for outpatient surgery provided on 
July 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve duplex scan. You say that medically necessary for procedure to be done. 
The Plan denied your request. The Plan says services can be provided by an in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a duplex scan to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services and crown lengthening services 
(D2950, D4249) provided on May 23, 2022 to June 27, 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 your benefit for the core buildup services has 
already been exhausted and coverage for the crown lengthening services have been denied 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 25, 2021. 
Therefore, we decided that the Plan does not have to pay for core buildup services and crown lengthening 
services (D2950, D4249) provided on May 23, 2022 to June 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests provided on 
August 29, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests. 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 $60 
copayment and a $50 copayment for outpatient diagnostic tests/outpatient diagnostic tests/diagnostic radiology 
services.  
 
You have been asked to pay a $60 copayment and a $50 copayment for outpatient diagnostic tests. The total 
amount you are being asked to pay is $110. This item/service falls within the outpatient diagnostic 
tests/outpatient diagnostic tests/diagnostic radiology services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for outpatient diagnostic tests provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dexamethasone sodium phosphate (J1100) injection 
(64483) provided on August 11, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you never received information on the 
doctors that are in-network. You say that you were told you would not have a copayment for prescriptions. You 
also say that all of the information you have been given has been plain misguidance and deceptive. The Plan 
denied your request. The Plan says prior authorization was not 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 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. Therefore, we 
decided that the Plan does not have to pay for the dexamethasone sodium phosphate (J1100) injection (64483) 
provided on August 11, 2022, by an out-of-network (OON) provider.   
Your complaint about being given misinformation is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided on July 8, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you were told it would be quicker to drive 
to the hospital. The Plan denied your request. The Plan says this service is not covered when there is no 
transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.   
The ambulance company did not provide transport services on July 8, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, 
no transport (A0998) provided on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontics (D6245) and crowns (D6740) for tooth #6, #7, 
#8, and #9 provided on June 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was medically necessary to have bridge work 
and partial bridges completed. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the teeth were extracted prior to the enrollee's effective date on this 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 when the services replace 1 or more teeth missing prior to the 
enrollees eligibility under the Plans contract. The documentation shows the enrollee had tooth #7 and #8 
removed prior to the start of the contract date of April 1, 2022. Therefore, we decided that the Plan does not 
have to pay for the pontics (D6245) and crowns (D6740) for tooth #6, #7, #8, and #9 provided on June 30, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the variable asphericity lens provided on August 23, 2022. 
 
 
 
 You asked the Plan to pay for the variable asphericity lens. You say that you were not informed about any 
payment before processing your order. You say you would not have purchased your glasses if you had been 
informed. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses. 
 
We looked at the file and the Plan's rules. Specifically, the service is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of the variable asphericity lens have not been met. 
Therefore, we decided that the Plan does not have to pay for the variable asphericity lens provided on August 
23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine ophthalmological examination including 
refraction provided by an out-of-network provider on June 21, 2022. 
 You asked the Plan to pay for the routine ophthalmological examination including refraction. You say that you 
say the bill was already paid by the insurance company. The Plan denied your request. The Plan says the 
provider was out-of-network. 
 
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 you receive them from an in-network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the routine ophthalmological examination 
including refraction have not been met. Therefore, we decided that the Plan does not have to pay for the routine 
ophthalmological examination including refraction provided by an out-of-network provider on June 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Topiramate. 
 
You asked the Plan to pre-approve Topiramate. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B benefit. 
 
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 pre-approve Topiramate.  
 
 
 Benefits for Topiramate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.