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

 
We decided that the Plan does not have to pay for the contact lens fitting (92310) provided on June 10, 2022. 
 
You asked the Plan to pay for the vision care. You say that you went for you annual eye exam. You say that 
you were advised the provider no longer accepts your insurance. You also say that you should be reimbursed. 
The Plan denied your request. The Plan says the benefit limit has been exhausted. 
 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.  
 
We looked at the file and the Plan's rules. The Plan contract states that contact lenses, instead of frames and 
lenses, are covered every 2 years. Based on this information, we decided that the Plan's rules for coverage of 
the vision care have not been met. The file shows that the Plan paid for contact lens fitting that you received on 
April 24, 2021, less than 2 years ago. Therefore, we decided that the Plan does not have to pay for the contact 
lens fitting (92310) provided on June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation with limited field 
of view - less than one whole jaw (code D0364) provided on June 14, 2022. 
 
You asked the Plan to pay for cone beam CT capture and interpretation with limited field of view - less than 
one whole jaw. The Plan denied your request. The Plan says there are no benefits available for this dental 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone 
beam CT capture and interpretation with limited field of view - less than one whole jaw (code D0364) provided 
on June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nasal tear duct probing provided on 
May 17, 2022. 
 
You asked the Plan to waive the copayment for the nasal tear duct probing. You say that you only went for an 
opinion on surgery and were not expecting the procedure to be done. 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 $260 
copayment for surgery or other services provided to you at an outpatient hospital. 
 
You have been asked to pay a $260 copayment for the nasal tear duct probing. This item/service falls within 
the surgery or other services provided to you at an outpatient hospital 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 the nasal tear duct probing provided on May 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you have a broken ankle and was put into 
a boot which is very heavy.  You say that you cannot get out of bed and need assistance in helping to get up to even go to the bathroom. The 
Plan denied your request. The Plan says based on Medicare guidelines and the information we have about your 
condition you do not meet the requirements for approval for continued SNF services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 continued SNF care. Our reviewer says 
that the requested continued SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found you are limited by your weight-bearing restriction and self-limiting 
behavior. Daily skilled services are not required to establish a maintenance program or to prevent deterioration 
of your condition. You do not have daily skilled nursing needs that require the specialized skill, knowledge, 
and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found that you 
do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued SNF care.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a complete mandibular denture (D5120) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that your benefit for the requested item or service has already been 
exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve a complete mandibular denture (D5120) 
provided by a participating provider. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on April 
21, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you never paid a 
copayment for ambulance services with your prior coverage. 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 for ambulance services. 
 
You have been asked to pay a $250 copayment for the ambulance services. This item/service falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
services provided on April 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a joint survey single view provided on April 21, 2022, by an 
OON provider. 
 
You asked the Plan to pay for a joint survey single view. You say that the member cannot choose which 
radiologist reads their diagnostic tests. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a joint survey single view provided on April 21, 
2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (CPT code E2377), harness 
for upgrade to expandable controller (E2313) and electronic connection between wheelchair controller and two 
or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the items have not been met. The upgraded electronics (expandable 
controller, harness and electronic connector to 2 power options) are not medically necessary. They are 
necessary when there is a medical need to control power options though the joystick. The notes do not show a 
medical need to control the power options through the joystick. The power options can be controlled using their 
own switches. These switches can be made any size without asking for a separate request. They can be made 
from any material without asking for a separate request. All of this can be done without the need to use the 
joystick to control the power features. Therefore, we decided that the Plan does not have to pre-approve the 
expandable controller (CPT code E2377), harness for upgrade to expandable controller (E2313) and electronic 
connection between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chiropractic services provided on October 
7, 2021. 
 
You asked the Plan to waive the coinsurance for chiropractic services. You say that you should only owe $30, 
nothing more. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for chiropractic services. The allowed amount of this item or service was $75.45, resulting in a 
coinsurance of $37.73 ($75.45 x 50% = $37.73). 
 
You have been asked to pay a $37.73 coinsurance for chiropractic services. This item/service falls within the 
chiropractic 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 coinsurance for chiropractic 
services provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth consultation provided on February 8, 2022, by an 
OON provider. 
 
You asked the Plan to pay for a telehealth consultation. You say that due to the ongoing crisis and less staff it 
wasn't possible for you to obtain the authorization before the services were rendered. The Plan denied your 
request. The Plan says the out-of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a telehealth consultation provided on February 8, 
2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) provided by an out-of-network 
provider on May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like the Plan should pay for this. 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 intraoral imaging (D0210) provided by an out-of-network provider on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the interim complete upper denture (D5810) 
provided on January 12, 2022. 
 
You asked the Plan to reimburse you for the denture. You say that you were advised by a plan representative 
that you had a $3,000 dental allotment. You also say that you were advised if you made the payment in full, 
you would be reimbursed. The Plan denied your request. The Plan says the interim complete denture is not 
listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the interim complete denture is not 
among those covered under this benefit.  
 
  
 
Therefore, we decided that the Plan does not have to reimburse you for the interim complete upper denture 
(D5810) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate mandibular and maxillary denture (D5140 and 
D5130) and an unspecified removable prosthodontic procedure (D5899) provided by a participating provider 
on March 28, 2022. 
 
You asked the Plan to pay for an immediate mandibular and maxillary denture and an unspecified removable 
prosthodontic procedure. You say that you thought this provider was in-network. The Plan denied your request. 
The Plan says these services have been correctly denied. 
 
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 an 
immediate mandibular and maxillary denture (D5140 and D5130) and an unspecified removable prosthodontic 
procedure (D5899) provided by a participating provider on March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair transit system. 
 
You asked the Plan to pre-approve the wheelchair transit system. You say that this equipment is necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the wheelchair transit system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vacuum erection device you received on May 18, 2022. 
 
You asked the Plan to pay for the vacuum erection device. You say that you were told this item would be 
covered. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that vacuum erection devices are non-covered for all 
indications. Therefore, we decided that the Plan does not have to pay for the vacuum erection device you 
received on May 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a septoplasty procedure provided on June 
15, 2022. 
 
You asked the Plan to waive the coinsurance for a septoplasty procedure. You say that you are trying to 
understand this bill and want to ensure you're paying the correct amount. 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 10% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. You have a maximum out of pocket (MOOP) amount of $530, which was not met at the time 
of this procedure, which is where the $293.44 charge came from. 
 You have been asked to pay a $293.44 coinsurance for a septoplasty procedure. This item/service falls within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 coinsurance for a septoplasty procedure 
provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) and intraoral  complete 
series of radiographic images (D0210) provided on May 31, 2022. 
 
You asked the Plan to pay for periodontal maintenance and intraoral  complete series of radiographic images. 
You say that the provider did x-rays on a new machine and cleaned your teeth and they advised you that they 
did a periodontic cleaning, which you did not ask for. The Plan denied your request. The Plan says there is no 
coverage for these services. 
 
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 
periodontal maintenance (D4910) and intraoral  complete series of radiographic images (D0210) provided on 
May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), and 
prophylaxis (D1110), provided by an out-of-network provider on March 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe these services should be 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 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 a periodic oral evaluation (D0120), bitewings (D0274), and prophylaxis (D1110), provided by an 
out-of-network provider on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye exam to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an eye exam. You say that you disagree with the denial for an OON eye 
exam. The Plan denied your request. The Plan says the requested services are not covered when received by an 
OON 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 
an eye exam to be provided by an out-of-network (OON) provider.