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

 
We decided that the Plan does not have to pay more for the prophylaxis (D1110) provided on February 21, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the prophylaxis. You say that the provider should not balance bill after the 
Plan's cost share. 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 OON provider. The Plan also 
says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 OON providers charges and the Plans payment. This 
cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided 
that the Plan does not have to pay more for the prophylaxis (D1110) provided on February 21, 2022 by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic continuous glucose monitor supplies. 
 
You asked the Plan to pre-approve therapeutic continuous glucose monitor. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for a therapeutic continuous glucose monitor. 
 
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 therapeutic continuous glucose monitor have not 
been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic continuous glucose 
monitor supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services provided on 
January 14, 2022, have been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), periodic oral evaluation - 
established patient (D0120), and bitewings - four radiographic images (D0274) provided March 4, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that services from this provider have been covered 
in the past. 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 Plan's 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 prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), and 
bitewings - four radiographic images (D0274) provided March 4, 2022, by an out-of-network (OON) provider.  
 
Your complaint about differences in how services were covered in the past 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessory, power seating system, tilt only 
(E1002). 
 
You asked the Plan to pre-approve power seating system, tilt only. You say that you are requesting an appeal to 
the adverse determination regarding a power mobility device for the enrollee. The Plan denied your request. 
The Plan says the enrollee does not meet the LCD criteria for power tilt seating. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 power seating system, tilt only. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided records do not document that the enrollee is high risk for 
development of a pressure ulcer and is unable to perform a functional weight shift or he utilizes intermittent 
catheterization for bladder management and is unable to independently transfer from the wheelchair to bed or 
that he has increased tone or spasticity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power seating system, tilt only have not been met. Therefore, we decided that 
the Plan does not have to pre-approve wheelchair accessory, power seating system, tilt only (E1002).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on March 28, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you needed to see the dentist due to your diabetes. 
The Plan denied your request. The Plan says a comprehensive periodontal evaluation (D0180) is not covered by 
your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
comprehensive periodontal evaluation (D0180) provided on March 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on October 6, 2021. 
 
You asked the Plan to waive the copayment for an injection. You say that you believe that this claim was 
denied. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $195 
copayment for each Medicare-covered ambulatory surgical center visit.  
 
You have been asked to pay $195 copayment for an injection. Injections fall 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 copayment for an injection provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on April 1, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that this was never an urgent care visit, 
and you shouldn't be charged as one. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $40 
copayment for services performed by a specialist for Medicare- covered services or provided by other health 
care professionals such as nurse practitioners or physician assistant.  
 
You have been asked to pay $40 copayment for office visit. Office visits fall within the Physician/ Practitioner 
Services, Including Doctors Office Visits 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 office visit provided on April 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator provided on March 9, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that you were out-of-town when the 
battery died in your portable oxygen concentrator. You say you found a provider who was able to assist you. 
The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
portable oxygen concentrator. We found no exception that would require the Plan to pay for the portable oxygen concentrator. Therefore, we decided that the Plan does not have to pay for the portable oxygen 
concentrator provided on March 9, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of foreign body (D7530) provided on March 23, 2022. 
 
You asked the Plan to pay for the removal of foreign body. You say that this service was not dental, but a 
necessary diagnostic test and procedure conducted by a licensed professional, and should be covered under 
your policy. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
plan. The Plan also says that you do not have a dental rider. 
 
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 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 removal of foreign body (D7530) provided on 
March 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the chiropractic manipulative treatment (98941) provided on
January 25, 2022.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service at issue was maintenance therapy, which is not eligible for payment per Medicare guidelines.
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 rules say that Medicare does not cover chiropractic maintenance care. Additionally, the rules say that a GA modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary, and they do have on file an advanced beneficiary notice (ABN) signed by the beneficiary. 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 plan has not substantiated their denial as they have not provided any medical records to verify that the services provided were for maintenance therapy. Additionally, the GA modifier alone is not enough to substantiate their denial, as it only indicates that the services might not be medically necessary. Therefore, we decided that the Plan has to pay for the chiropractic manipulative treatment (98941) provided on January 25, 2022.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) and 
consultation (D9310) provided on December 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a comprehensive periodontal evaluation (D0180) and consultation 
(D9310) are not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
comprehensive periodontal evaluation (D0180) and consultation (D9310) provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office visits provided on 
February 16, 2022, and February 25, 2022. 
 
You asked the Plan to waive the copayments for specialist office visits. You say that you shouldn't be charged 
for both visits, you thought the one was going to be the surgery, but it wasn't. The Plan denied your request. 
The Plan says the copayments applied are correct. 
 
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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
 
 
 You have been asked to pay a total of $90 ($45 x 2 visits) copayment for specialist office visits. Specialist 
office visits fall within the Physician/Practitioner Services, Including Doctors Office Visits 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 copayments for specialist office visits provided on February 16, 2022, and 
February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader for the enrollee. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 day reader. You say that this is medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
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, 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 14 day reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14 day reader for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 11, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit at issue in this appeal. The Plan did not pre-approve the 
office visit at issue. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for office visit provided on April 11, 2022, by an out-of-network 
(OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs rehabilitation after 
two weeks in bed and it is recommended that the enrollee go to an LTACH. The Plan denied your request. The 
Plan says there is no documentation that the enrollee will benefit from and improve with LTACH management. 
The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional 
services. With additional time in the current setting, clinical stability can be ensured such that the appropriate 
lower level of care can be determined. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be somewhat unstable for transfer due to no long-term 
feeding access established. The enrollee should only require short-term additional acute care services that can 
be safely administered at the current facility until more appropriate for a lower level of care. The enrollee does 
not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary as the enrollee is not yet stable for transfer and 
as it would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray provided on November 8, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that you have an exclusive contract with the nursing home 
facility and only you can come into the facility to perform the service. The Plan denied your request. The Plan 
says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the x-
ray. We found no exception that would require the Plan to pay for the x-ray. The records provided for review 
do not show that the x-ray was urgent or emergent. Therefore, we decided that the Plan does not have to pay for 
the x-ray provided on November 8, 2021, by an out-of-network (OON) provider.