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

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99203) or pay 
for the determination of refractive state (92015) provided on June 30, 2022, by an out-of-network (OON) 
provider. 
 You asked the Plan to waive the copayment for the outpatient office visit and to pay for the determination of 
refractive state. The Plan denied your request. The Plan says this cost sharing was charged correctly for the 
outpatient office visit. The Plan also says that the determination of refractive state is not covered. 
 
 
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 $65 
copayment for specialists office visit rendered by an out-of-network provider under the Vision care benefit 
category. 
 
You have been asked to pay a $65 copayment for the outpatient office visit (99203). This service falls within 
the Vision care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. The contract also clearly states that Original Medicare does not cover routine eye exams (eye refractions). 
The record shows that you received an exam for the diagnosis of Pigmentary retinal dystrophy. Determination 
of refractive state is not covered for this visit because it was not a routine exam. The record also shows that you 
signed a document at the provider's office stating you understood refractions are not covered by most insurance 
companies. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient office 
visit (99203) or pay for the determination of refractive state (92015) provided on June 30, 2022, by an out-of-
network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99310 provided on May 10, 2022. 
 
You asked the Plan to pay for procedure code 99310. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. In this case, the Plan did not provide enough evidence to support the denial of 
payment for procedure code 99310 based on Medicare criteria. Therefore, we decided that the Plan has to pay 
for procedure code 99310 provided on May 10, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an in-network Medicare Part B drug (eye 
injections) and specialty visit provided on September 16, 2022. 
 
You asked the Plan to waive the cost for an in-network Medicare Part B drug and specialty visit. You say that 
you weren't aware of the costs associated with these services and should have been told before the injections 
were 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 $35 
copayment for physician/practitioner services, including doctor's office visits and a 20% coinsurance for 
Medicare Part B prescription drugs. You have a $35 copayment for the specialist office visit, and a 20% 
coinsurance amount of $730.32 ($730.32 + $35 = $765.32). 
 You have been asked to pay a $765.32 for an injection and specialty visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits and Medicare Part B prescription drug 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 cost for an in-network Medicare Part B drug (eye injections) 
and specialty visit provided on September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) and the 
intraoral-periapical first radiographic image (D0220) provided on October 20, 2022. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided 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 
limited oral evaluation-problem focused (D0140) and the intraoral-periapical first radiographic image (D0220) 
provided on October 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on August 30, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
assisted living facility where the enrollee resides has a protocol to call the ambulance when someone falls and 
hits their head. You also say that after the enrollee was evaluated a decision was made not to transport him to 
the hospital. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 August 30, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral appliance (D9944) provided on August 30, 2022. 
 
You asked the Plan to pay for the oral appliance. You say that the oral appliance was already approved. The 
Plan denied your request. The Plan says the oral appliance is not covered by Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the oral appliance (D9944) 
provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on June 24, 2022. 
 
You asked the Plan to pay for an eye refraction (92015). You say that you are appealing with supporting 
records. 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 eye refraction 
(92015) provided on June 24, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit provided on July 27, 2022. 
 
You asked the Plan to pay for psychotherapy visit. You say that you have a PPO insurance to pay for out-of-
network provider, so the billed service should be covered. The Plan denied your request. The Plan says this 
provider has chosen to opt out of Medicare. Medicare does not pay for any covered items or services you get 
from an opt out doctor or other provider. 
 
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 
psychotherapy visit provided on July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97810, 97811) 
rendered by the out-of-network (OON) provider from May 13, 2022, through May 27, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 
rendered by an out-of-network provider, without prior authorization. 
 
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 issue reimbursement 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 had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to issue reimbursement for these services. Therefore, we 
decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97810, 97811) 
rendered by the out-of-network (OON) provider from May 13, 2022, through May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture reline (D5760) provided on 
November 3, 2022. 
 
You asked the Plan to pay for a maxillary partial denture reline. You say that you do not know why dentures 
would not be included. The Plan denied your request. The Plan says the denied dental service is not a covered 
benefit 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
maxillary partial denture reline (D5760) provided on November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid provided on December 22, 2020. 
 
You asked the Plan to pay for the hearing aid. You say that you should not be responsible for the bill because 
the provider did not send the claim in a timely fashion. You say you would like the claim reprocessed. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hearing aid was not filed until October 14, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the hearing aid provided on December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral radiographic 
images (D0220), and a root canal (D3330) for tooth #19 provided on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that the in-network providers did not have any 
available appointments. 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. Also, it was verified that the 
enrollee was informed that the provider was 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. 
 
  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 limited oral evaluation (D0140), intraoral radiographic images (D0220), and a root canal (D3330) 
for tooth #19 provided on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the sales tax (D9985) for dental services provided on September 
22, 2022. 
 
You asked the Plan to pay the sales tax. You say that this service should be covered, and you are appealing the 
denial. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the sales tax 
(D9985) for dental services provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided by an out-of-network provider on 
August 5, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you had to throw away your old hearing aids 
because they were not good. You say you want to be reimbursed for the hearing aids. The Plan denied your 
request. The Plan says there is no out-of-network coverage for hearing aids. 
 
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 provided through the Plan's network of providers.  
 
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 aids provided by an out-of-network provider on August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic imaging (D0330), and intraoral 
imaging (D0220 and D0230) provided on October 10, 2022. 
 
You asked the Plan to pay for panoramic radiographic imaging and intraoral imaging. You say that you would 
like the Plan to pay for these images. The Plan denied your request. The Plan says the denied 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 
panoramic radiographic imaging (D0330), and intraoral imaging (D0220 and D0230) provided on October 10, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 11, 
2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that this evaluation was important to have. The 
Plan denied your request. The Plan says the denied service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM). 
 
You asked the Plan to pay for a continuous glucose monitor (CGM). You say that the services requested are 
medically necessary. The Plan denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to 
pay for a continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF services provided on July 17, 2022. 
 
You asked the Plan to waive the copayment for SNF services. You say that you were unaware the facility was 
out-of-network. 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 30% 
coinsurance for each out-of-network Medicare-covered SNF stay.  
 
You have been asked to pay a total coinsurance of $1,144.11, which is 30% of the allowed amount for SNF 
services ($3,813.70 allowed x 30% = $1,144.11). This item/service falls within the skilled nursing facility care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) 
services provided on July 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5213) and a partial 
mandibular denture (D5214). 
 
You asked the Plan to pre-approve the dentures. You say that you are unhappy with the dentures you received 
on March 7, 2022. The Plan denied your request. The Plan says your benefit for the requested items or services 
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 items or services was exhausted on date of service March 7, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture (D5213) and a 
partial mandibular denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 7, 2022, to September 21, 
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 September 7, 2022, to September 21, 2022.