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

 
We decided that the Plan does not have to pay an additional amount for the periodontal maintenance (D4910) 
provided on November 17, 2021.  
You asked the Plan to pay an additional amount for the periodontal maintenance. You say that this claim 
should be covered in full. You say that it was a standard cleaning. You say that it should be covered at 100% 
and not subject to a deductible. The Plan denied your request. The Plan says oral hygiene instruction is not 
listed as a covered service. The Plan also says that periodontal maintenance is considered a basic dental service. 
The Plan also says there is a 30% coinsurance for periodontic services, including periodontal maintenance. 
 
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, periodontal maintenance is listed as a 
periodontic procedure. The Evidence of Coverage says there is a $100 deductible for comprehensive dental 
services that must be met before payment can be applied. This is a contractual obligation you agreed to when 
you enrolled in the Plans dental coverage. Therefore, we decided that the Plan does not have to pay an 
additional amount for the periodontal maintenance (D4910) provided on November 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from October 9, 2021, to October 27, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the 100 day benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from May 20, 2021 to 
October 8, 2021. The Plan has covered 100 days of SNF care.   
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from 
October 9, 2021, to October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
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 perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and 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 assesses 
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 continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 
81455 are denied as not medically necessary. 
 
We looked at the file and Medicare rules. The services are billed under code 81455. 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 pay for the laboratory services rendered on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on November 9, 2021. 
 
You asked the Plan to pay for the dental service. You say that you need this denture to eat. You also say that 
this dentist is in network. The Plan denied your request. The Plan says partial denture 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the partial denture is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper 
denture (D5213) provided on November 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291),  bronchoscopy (31622) and 
tracheotomy tube change (31502) provided on October 18, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the critical care, bronchoscopy and tracheotomy tube change services. You say 
that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan 
says the last covered day for the inpatient level of care was August 25, 2021. 
 
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. Additionally, the record indicates that the provider was aware that coverage for inpatient 
services ended prior to this date of service. 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 critical care services (99291),  
bronchoscopy (31622) and tracheotomy tube change (31502) provided on October 18, 2021 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 periodontal maintenance (D4910) provided November 
10, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that it is necessary for you to follow this 
cleaning regimen. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
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. The Plan covers the 
periodontal maintenance three times per plan year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal 
maintenance was previously covered on February 3, 2021, May 5, 2021, and August 25, 2021. Based on this 
information, we decided that the Plan's frequency limit for coverage of the periodontal maintenance has been 
exceeded. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) 
provided November 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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.  The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for infection of 
prosthetic joint of the knee, sepsis, and altered mental status. The enrollees medical problems are stable. There 
are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digital, binaural, bte (V5261) provided 
August 24, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you did not know that this provider was not in 
network. But you had purchased the hearing aids since you thought the cost was more appropriate. The Plan 
denied your request. The Plan says the claim was processed correctly per the Evidence of Coverage. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the designated in-network vendor.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aid, digital, binaural, bte (V5261) provided August 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sigmoidoscopy, flexible (45346) provided November 22, 
2021. 
 
You asked the Plan to pay for the outpatient procedure. You say that you were told by a Plan representative that 
the doctor is in-network and you feel that the services should be covered. The Plan denied your request. The 
Plan says the claim was processed with the correct cost share applied. 
 
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 20% coinsurance after the $250 deductible which applies to Outpatient 
hospital services.  
 
The item or service you asked the Plan to pay for falls within the benefit category Outpatient hospital services. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is 20% coinsurance after 
the $250 deductible which applies to Outpatient hospital services. This cost sharing is a contractual obligation 
that had not been met at the time the outpatient procedure was received on November 22, 2021. Therefore, we 
decided that the Plan does not have to pay for the sigmoidoscopy, flexible (45346) provided November 22, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive (92014) 
provided December 3, 2021. 
 
You asked the Plan to pay for the eye exam. You say that your new doctor asked you to get a new eye exam. 
The Plan denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
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 one eye exam every 12 months. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that an eye exam was 
previously covered on February 12, 2021. Based on this information, we decided that the Plan's frequency limit 
for coverage of the eye exam has been exceeded. Therefore, we decided that the Plan does not have to pay for 
the ophthalmological services: medical examination and evaluation, with initiation or continuation of 
diagnostic and treatment program; comprehensive (92014) provided December 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor and supplies 
(K0554, K0553) provided on November 10, 2021. 
 
You asked the Plan to pay for a Freestyle Libre continuous glucose monitor and supplies. You say that this is 
supported in the records. The Plan denied your request. The Plan says there is not a proof of delivery in the file. 
 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 and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for a Freestyle Libre continuous glucose monitor and supplies (K0554, K0553) provided on 
November 10, 2021.  
 
Your complaint about the Plans interpretation of Medicare policies 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 4, 2021. 
 
You asked the Plan to pay for the physician's services. You say that you have visited this doctor for years and it 
always covered by your HMO Plan. You say that you did not know at the time of your visit that this doctor is 
not in-network anymore and your insurance card was accepted by the doctor's office. The Plan denied your 
request. The Plan says the service 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated dental abutments (code D6056) and the 
maxillary partial denture (code D5211) you received on November 3, 2021. 
 
You asked the Plan to pay for the dental abutments and partial denture. You say that these services were 
medically necessary and should be covered. The Plan denied your request. The Plan says you do not have 
coverage for enhanced 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. The Plan contract states that 
the dental benefit includes coverage only for the dental services explicitly listed in the dental coverage list. 
Neither dental abutments nor partial dentures are listed as covered benefits.  That means that these services are 
never covered, regardless of the appropriateness of these services. 
 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 
prefabricated dental abutments (code D6056) and the maxillary partial denture (code D5211) you received on 
November 3, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the electrocardiogram (ECG) you received on September 
29, 2021. 
 
You asked the Plan to hold you harmless for the ECG. You say that this claim should be paid The Plan denied 
your request. The Plan says that the provider has not sent in medical records, so the claim cannot be processed. 
 
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. Specifically, the doctor who provided these services (and from whom medical 
records would be needed) is a contract provider with the Plan.  That means that the Plan is considered to be in 
control of these medical records.  It is not appropriate for you to be held financially liable for a service 
provided by a contract provider simply because the Plan can't get records from their own provider. Therefore, 
we decided that the Plan has to hold you harmless for the electrocardiogram (ECG) you received on September 
29, 2021.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on September 22, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was not in hospice. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 6, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the physician 
services provided on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a comprehensive genomic profile, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on July 14, 2021.