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

 
We decided that the Plan does not have to pay an additional amount for the root canal (D3330) provided on 
September 9, 2021, by the out of network provider. 
 
You asked the Plan to pay an additional amount for the dental service. You say that you received a check for 
$262.50. You also say that you should be reimbursed for the full $700. The Plan denied your request. The Plan 
says the reimbursement amount of $262.50 was correct. 
 
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 and root canal is listed as covered, there 
is a 50% coinsurance that applies to covered supplemental comprehensive services that you receive out of 
network. The record shows that the Plan' paid 50% of the allowed amount, $525 x 50% = $262.50. 
Additionally, out of network providers may bill you for any amount greater than what the plan pays the 
provider. $700 - $525 = $175. $175 + $262.50 = $437.50. Therefore, we decided that the Plan does not have to 
pay an additional amount for the root canal (D3330) provided on September 9, 2021, by the out of network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites - two surfaces, anterior (D2331) 
and unspecified diagnostic procedure, by report (D0999) provided January 10, 2022. 
 
You asked the Plan to pay for the fillings and unspecified diagnostic procedure. You say that you have not had 
an issue with claims from this provider in the past. The Plan denied your request. The Plan says this service is 
not covered 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 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 resin-
based composites - two surfaces, anterior (D2331) and unspecified diagnostic procedure, by report (D0999) 
provided January 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from July 3, 2021, to August 2, 2021. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you would like to appeal your 
copayment for the services that were rendered. The Plan denied your request. The Plan says the proper 
copayment was applied, and the claim processed appropriately. 
 
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 $0 
copayment Per admission, for days 1-20 and a $40 copayment per day for days 21- 100. From July 3, 2021, to 
August 2, 2021, the total days in the SNF was 31 days. The total chargeable days for the SNF stay was 10 days 
with a copayment of $400 ($40 copayment per day x 10 days). You have been asked to pay a $400 copayment for the SNF stay. The SNF stay falls within the Skilled nursing 
facility (SNF) 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 a skilled nursing 
facility (SNF) stay provided from July 3, 2021, to August 2, 2021.  
 
Your complaint about your experience with this provider 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5130) provided on October 12, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that the Plan's provider is inaccessible to you. The Plan 
denied your request. The Plan says hearing aids are only covered when they are purchased through the 
specified hearing vendor network. 
 
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 they are purchased from the Plans specified routine hearing vendor and are the 
vendors own branded advanced or premium hearing aids.  
 
We looked at the file and the Plan's rules. The hearing aid in this case was not purchased through the specified 
vendor and is not the covered brand allowed by the Plan. Based on this information, we decided that the Plan's 
rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to 
pay for the hearing aid (V5130) provided on October 12, 2021.  
 Your complaint about the accessibility of the Plans provider for supplemental (non-Medicare-covered) 
benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) additional chiropractic care visits. 
 
You asked the Plan to pre-approve five (5) additional chiropractic care visits. You say that additional 
chiropractic care is medically necessary. The Plan denied your request. The Plan says additional chiropractic 
care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 five (5) additional chiropractic care 
visits. Our reviewer says that additional chiropractic care is does not meet the Medicare coverage criteria. Our 
physician reviewer found that a patient's condition is considered chronic when it is not expected to significantly 
improve or be resolved with further treatment (as is the case with an acute condition) but where the continued 
therapy can be expected to result in some functional improvement. Once the clinical status has remained stable 
for a given condition, without expectation of additional objective clinical improvements, further manipulative 
treatment is considered maintenance therapy and is not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of five (5) additional chiropractic care visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve five (5) additional chiropractic care visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
January 5, 2022. 
 
You asked the Plan to pay for dental services. You say that there is no other suitable alternative for you but to 
go out-of-network. The Plan denied your request. The Plan says services provided by an out-of-network 
provider is not covered. 
 
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 dental 
services provided by an out-of-network provider on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0364), and intraoral imaging 
(D0220) provided by a participating provider on November 30, 2021. 
 
You asked the Plan to pay for a cone beam CT capture and intraoral imaging. You say that you were told that 
these services would be covered. The Plan denied your request. The Plan says the benefit limit for D0220 has 
already been exhausted. The Plan says that D0364 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 Plan's coverage rules apply in this case. The Plan covers an intraoral 
imaging once per calendar year. A cone beam CT capture is not a covered benefit. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of intraoral imaging have already been met. A cone beam CT capture is not a covered dental benefit. 
Therefore, we decided that the Plan does not have to pay for a cone beam CT capture (D0364), and intraoral 
imaging (D0220) provided by a participating provider on November 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist physician services provided on November 24, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist physician services. You say that you do not need a primary care 
physician referral per your contract and would like the claim reprocessed for payment. The Plan denied your 
request. The Plan says the rendering provider is an out-of-network provider and there was no referral from an 
in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 the specialist physician services provided on 
November 24, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing services provided on October 12, 2021.
You asked the Plan to pay for the laboratory testing services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed according to Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the laboratory testing services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing services provided on October 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasounds provided on October 4, 
2021, and November 29, 2021, 
 
You asked the Plan to waive the copayment for the ultrasounds. You say that you don't believe you should pay 
a copay. The Plan denied your request. The Plan says the copayment applied 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 $130 
copayment for Medicare-covered radiological diagnostic services.   
 You have been asked to pay a total of $260 ($130 x 2) for the ultrasounds. Ultrasounds fall within the Other 
outpatient diagnostic tests-Radiological diagnostic services, not including x-rays 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 ultrasounds provided on October 4, 2021, and November 29, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Myrbetriq for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120) provided on December 7, 2021. 
 
You asked the Plan to pay for the oral exam. You say that your oral exam provided in September was due to an 
emergency situation, and you feel that it should not be counted toward your annual limit. The Plan denied your 
request. The Plan says your benefit covers a maximum of two oral exams per calendar year. You had oral 
exams provided on June 1, 2021, and September 1, 2021. The oral exam provided on the date in question 
exceeded the frequency limitation of your benefit. 
 
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 Plan's dental benefit 
coves two oral exams per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the oral exam is requested in a 
frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the periodic oral exam (D0120) provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown (D2752) to be provided by an out-of-network provider. 
 
You asked the Plan to pay for a crown. You say that D2752 is medically necessary. The Plan denied your 
request. The Plan says that the criteria for D2752 has not been met for tooth #6. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown when 
the services are medically necessary and reasonable. 
 
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 a crown. Our reviewer says that criteria has 
been met. Our physician reviewer found the documentation provided meets the criteria for coverage for a 
crown restoration (D2752) for tooth #6. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have been met. Therefore, we decided that the Plan has to pay for a 
crown (D2752) to be provided by an out-of-network 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because 
the requested LTACH care is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare criteria for coverage. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vein surgery.
You asked the Plan to pre-approve varicose vein surgery. You say that this is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met as neither sclerotherapy nor phlebectomy are approved for veins smaller than 4mm.
The Plan follows Medicare rules. Medicare rules say that varicose vein surgery is subject to the criteria listed in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve varicose vein surgery. Our reviewer says that the requested varicose vein surgery is not medically reasonable and necessary. Our physician reviewer found that the documentation does not meet any of the coverage criteria for the requested vein surgery. There is not satisfactory documentation that the patient is having significant pain interfering with activities of daily living. Additionally, coverage of phlebectomy of venous tributaries requires that the associated saphenous reflux has already been treated or is not present. In this case there is saphenous reflux in the territory of interest. Coverage criteria require that the veins to be treated be greater than 4 mm in diameter to qualify for coverage. There is no satisfactory documentation of vein diameter with respect to those veins slated for phlebectomy. Therefore, coverage criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of varicose vein surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve varicose vein surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 2 sensor Kit 
 
You asked the Plan to pre-approve Freestyle Libre 2 sensor Kit. You say that you are a diabetic and have to 
check your blood sugar sometimes 3 to 4 times a day. Due to these reasons, you feel the Plan should cover this 
Freestyle Libre 2 sensor. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not 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 Freestyle Libre 2 sensor Kit have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 2 sensor Kit