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

 
We decided that the Plan does not have to pay for the pontic - resin with predominantly base metal (D6251) 
provided on September 26, 2022. 
 
You asked the Plan to pay for the pontic (D6251). You say that you believe all or at least part of the work 
performed should be covered by your insurance. You say you believed the composite build-up was covered by 
insurance. 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 pontic - resin with predominantly 
base metal (D6251) is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the pontic - resin with predominantly base metal (D6251) provided on September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 Continuous glucose monitoring (CGM) 
system. 
 
You asked the Plan to pre-approve the Dexcom G6 CGM system. You say that the records provided support the 
necessity of the service in dispute. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria. 
 
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the Dexcom G6 CGM system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 Continuous glucose monitoring 
(CGM) system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on June 3, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says there is no documented assessment to support the enrollee was 
expected to require a hospital stay over two midnights. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found it was not expected that the enrollee would require hospital services that would likely 
cross 2 midnights due to low severity and low complexity of the presentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on June 27, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you are disputing the share cost. 
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 $40 
copayment for Outpatient hospital services. 
 
You have been asked to pay a $40 copayment for an office visit. This item/service falls within the Outpatient 
hospital 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 an office visit 
provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 6, 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 February 1, 2022, and 
May 16, 2022. Therefore, we decided that the Plan does not have to pay for the dental services on December 6, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility stay provided on March 26, 2022, to 
August 31, 2022. 
 
You asked the Plan to pay for a skilled nursing facility stay. You say that you do not understand why these 
services have been denied. The Plan denied your request. The Plan says the rendering facility does not 
participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a skilled 
nursing facility stay provided on March 26, 2022, to August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 27, 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 March 4, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing amounts for the 4 physical therapy services, 
and surgical services, and to pay for the self-administered drugs provided in an outpatient setting from October 
3, 2022, to October 4, 2022. 
 
You asked the Plan to waive the cost sharing amounts for the outpatient services and pay for the self-
administered drugs. You say that you were admitted to the hospital and stayed overnight after your surgery. 
You say that this should be covered under Medicare Part A. You say that you were given your regular 
medication while staying overnight at the order of your doctor. You also say that you feel these services should 
be covered. The Plan denied your request. The Plan says self-administered drugs provided in an outpatient 
setting are not covered under Medicare Part B. 
 
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 $40 
copayment for Outpatient Rehabilitation Services, and a $250 copayment for Outpatient Hospital. The rules say 
that Medicare Part B generally does not pay for self-administered drugs. 
 
You have been asked to pay a $103.70 copayment ($40 x 4 physical therapy services) and a $250 copayment 
for the outpatient services. These services fall within the Outpatient Rehabilitation Services, and Outpatient 
Hospital benefit categories. The record shows that the allowed amount for the physical therapy services was 
less than the total of $40 x 4, thus the $103.70 copayment. The record also shows that the services you received 
were outpatient and therefore not coverable under Medicare Part A. 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. Additionally, the self-administered drugs provided here are not 
among the types covered under Medicare Part B. Therefore, we decided that the Plan does not have to waive 
the cost sharing amounts for the 4 physical therapy services, and surgical services, and to pay for the self-
administered drugs provided in an outpatient setting from October 3, 2022, to October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 17, 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 June 17, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial and subsequent observation care provided from 
June 6, 2022, to June 9, 2022. 
 
You asked the Plan to pay for the observation care. You say that the enrollee was not enrolled in hospice on the 
dates of service. 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 June 6, 2022. 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 initial and subsequent 
observation care provided from June 6, 2022, to June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and tooth extraction (D0140, 
D7140) provided on October 31, 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 and charges. The Plan denied your request. The Plan says the limited oral evaluation denied 
correctly as it does not fall within your dental benefits. The cost-sharing for the dental extraction applied 
correctly based on your contract with 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, limited oral evaluations are not among 
those covered under this benefit.    
 
You have also been asked to pay a 50% coinsurance for a tooth extraction (D7140). 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 pay for a limited oral evaluation and 
tooth extraction (D0140, D7140) provided on October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiograph image (D0330) provided on 
October 18, 2022. 
 
You asked the Plan to pay for the dental service. You say that you moved and went to a new dentist, and they 
decided to do new x-rays. 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 the date of service of October 1, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiograph image (D0330) 
provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 28, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided 
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 an office visit provided 
on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided on October 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told the provider was in-
network. 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. The Plan also 
says that your benefit for bitewing x-rays (D0274) 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. The record shows your benefit for bitewing x-rays (D0274) was exhausted on the appealed claim. 
 
Dental Code Billed Amount Allowed Amount Plan Paid Your Responsibility 
D0274 $35 $0 $0 $35 
D0274 $72 $29 $29 $43 D1110 $92.75 $46 $46 $46.75 
D0150 $88.50 $30 $30 $58.50 
D1208 $35.75 $18 $18 $17.75 
D0220 $31 $12 $12 $19 
D0230 $15.50 $9 $9 $6.50 
Total    $226.50 
 
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 the dental services provided on October 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 28, 
2022, through May 29, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the low severity and low complexity of the presentation and stability of the 
patient following initial treatment in the emergency department, it was not expected that the enrollee would 
require hospital services that would likely cross 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from May 28, 2022, through May 29, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 17, 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 services are not covered 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 dental 
services on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
August 29, 2022. 
 
You asked the Plan to pay for the determination of refractive state. You say that you and the enrollee were 
unaware that part of this examination would not be covered by the enrollee's insurance. You also say that if this 
claim is denied, the enrollee will have to pay monthly for the service because they are on a very strict budget. 
The Plan denied your request. The Plan says the enrollee was seen by an Ophthalmologist on this date of 
service. The Plan also says that the enrollee signed a notification of non-covered services on August 29, 2022, 
acknowledging that the refraction was not covered. 
 
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 this service when it is performed as part of a routine vision eye exam by an 
optometrist. 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that the enrollee was seen by an 
Ophthalmologist on this date of service, and not by an optometrist for a routine vision exam. Based on this 
information, we decided that the Plan's rules for coverage of the determination of refractive state have not been 
met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) 
provided on August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that BiPAP has not been effective in maintaining 
the enrollee's COPD. The Plan denied your request. The Plan says the enrollee has not failed BiPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our physician 
reviewer found that the enrollee has a diagnosis of COPD and heart failure. She was recently hospitalized with 
acute respiratory failure. The arterial blood gas (ABG) was consistent with acute on chronic hypercarbic 
respiratory failure. An echocardiogram showed heart failure with preserved ejection fraction (HFpEF) with 
severe pulmonary hypertension. The enrollee had not been taking diuretics at home as prescribed.  There are no pulmonary function tests to gauge the severity of the COPD. There is no ABG done while stable 
to document chronic carbon dioxide (CO2) retention. If the enrollee does have chronic CO2 retention, she may 
benefit from BiPAP with AVAPS during sleep as an outpatient. However, Medicare does not cover a home 
ventilator when used as BiPAP. Therefore, a home ventilator is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.