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

 
We decided that the Plan does not have to pay for the extraction of tooth #31 (D7210) provided on January 12, 
2022. 
 
You asked the Plan to pay for an extraction. You say that you were misled about your dental benefits and the 
extraction should be covered. The Plan denied your request. The Plan says your annual dental benefit 
maximum has already been met. 
 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 this benefit includes 
coverage up to $200 for supplemental preventive and comprehensive dental services. 
 
The record shows your annual dental benefit has been exhausted and you are responsible for any amount above 
the benefit limit. You have been asked to pay $311 for an extraction on January 12, 2022. This item/service 
falls within the dental services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the extraction of tooth #31 
(D7210) provided on January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. 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 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 laboratory services provided on June 17, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for durable medical equipment (DME) 
provided on September 24, 2021, to October 24, 2021. 
 
You asked the Plan to waive the deductible for durable medical equipment (DME). You say that you disagree 
with the cost-share applied on September 24, 2021 and October 24, 2021. 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 $79.12 
deductible for durable medical equipment (DME). 
 
You have been asked to pay a $79.12 deductible for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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. Your deductible is $198. Until you have paid your deductible, you must pay 
the full cost of your covered services. Therefore, we decided that the Plan does not have to waive the 
deductible for durable medical equipment (DME) provided on September 24, 2021, to October 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on May 17, 2022, by an OON 
provider. 
 
You asked the Plan to pay for a telehealth visit. You say that due to the ongoing crisis it was not possible to 
obtain the authorization prior to the services being 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 visit provided on May 17, 2022, by an 
OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from May 15, 
2022, to May 17, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you thought that if you were 
admitted through the ER that the inpatient copayment would be waived. 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 $195 
copayment each day, for days 1-5 for inpatient hospital care ($195/day x 2 = $390).  
 
You have been asked to pay a $390 copayment for an inpatient stay. This item/service falls within the inpatient 
hospital 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 an inpatient stay provided 
from May 15, 2022, to May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the receiver (Monitor), dedicated, for use with 
therapeutic continuous glucose monitor system (K0554) and supply allowance used with a therapeutic CGM 
device (K0553). 
 
You asked the Plan to pre-approve the CGM device and supplies. You say that you are appealing the denial for 
the Freestyle Libre 2. The enrollee takes insulin 4 times a day. The Plan denied your request. The Plan says the 
enrollee does not meet all of the criteria as the records do not show a requirement for 3 or more insulin 
injections a day, and an insulin pump or frequent adjustment of insulin based on results from a 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 the CGM device and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the receiver (Monitor), dedicated, for use 
with therapeutic continuous glucose monitor system (K0554) and supply allowance used with a therapeutic 
CGM device (K0553).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4305 billed for dates of service October 4, 2021, to 
October 10, 2021. 
 
You asked the Plan to pay for code A4305. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says this code is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Disposable drug delivery systems, including 
code A4305 are non-covered devices because they do not meet the Medicare definition of durable medical 
equipment. You billed with non-covered code A4305. Therefore, we decided that the Plan does not have to pay 
for code A4305 billed for dates of service October 4, 2021, to October 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dentures. 
 
You asked the Plan to pre-approve dentures. You say that you don't understand why you cannot use your dental 
benefit towards the dentures. The Plan denied your request. The Plan says this service is not covered under 
your 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 pre-approve 
dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable oxygen concentrator (E1392) provided on April 
26, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that the items should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as they 
were non-emergent and could be provided in-network. 
 
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 portable oxygen concentrator (E1392) provided 
on April 26, 2022 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says the enrollee has exhausted their 100-day 
limit for inpatient services in a SNF. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from April 25, 2022, 
to October 25, 2022. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for brief technology based check-in provided on May 8, 2022. 
 
You asked the Plan to pay for brief technology based check-in. You say that this should have been covered 
because the provider is in-network. The Plan denied your request. The Plan says this is not covered because it 
is excluded by Medicare and by your 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. The Plan rules say that they 
cover medically necessary dental services, as covered by original Medicare. 
 
 
  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 brief 
technology based check-in provided on May 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for removal impacted cerumen requiring instrumentation, unilateral  
(code 69210) provided on February 24, 2022. 
 
You asked the Plan to pay for removal impacted cerumen requiring instrumentation, unilateral. You say that 
these services are separate from the office visit. The Plan denied your request. The Plan says that the service 
billed 69210 states removal requiring instrumentation. 
 
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. Specifically, the Plan has not provided us with the correct code or the rule to 
support the denial. Therefore, we decided that the Plan has to pay for removal impacted cerumen requiring 
instrumentation, unilateral (code 69210) provided on February 24, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 12, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that the services were a medical necessity. 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 an office visit provided on April 12, 2022, by an 
OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care (99308) provided on March 23, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not 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 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 nursing facility care (99308) provided on March 
23, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on October 24, 2020, 
to October 29, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 $360 
copayment per day for days 1-5 and $0 per day for days 6-90 for Medicare-covered services. Include inpatient 
acute, impatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient 
hospital care starts the day you are formally admitted to the hospital with a doctors order. The day before you 
are discharged is your last inpatient day. There were 5 days. 5 x $360 = $1,800. Therefore, results in the total 
cost sharing amount of $1,800.  
 
 You have been asked to pay a $360 copayment per day for inpatient hospital stay. This item/service falls within 
the Inpatient hospital 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 inpatient 
hospital stay on October 24, 2020, to October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and testing services (99204, 36415, 95004) 
provided on May 26, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and testing services. You say that the services should be covered 
as you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as 
they were non-emergent and prior authorization was not 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 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 an office visit and testing services (99204, 36415, 
95004) provided on May 26, 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 a recliner chair. 
 
You asked the Plan to pre-approve a recliner chair. You say that you have severe arthritis of your whole body. 
The requested recliner chair is needed. The Plan denied your request. The Plan says a recliner chair is furniture 
and is not used to care for a medical problem. Neither Medicare nor your health plan cover a recliner chair. 
 
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 a recliner chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on May 
17, 2022, to May 25, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were discharged 
too early from a previous stay, and you feel you should not have to pay the second copayment. 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 $375 
copayment for inpatient hospital care. 
 
You have been asked to pay a $375 copayment for the inpatient hospital care. This item/service falls within the 
inpatient hospital 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 file shows you were in the hospital from May 17, 2022, to May 25, 2022. Per the 
EOC, there is a $125 copayment per day for days 1-3 per admission. Therefore, the total for your stay is $375. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care 
provided on May 17, 2022, to May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided on 
May 26, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you should not be 
responsible to pay this. 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 20% 
coinsurance for durable medical equipment. 
 
You have been asked to pay 20% coinsurance for durable medical equipment. This item/service falls within the 
durable medical equipment 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 durable 
medical equipment provided on May 26, 2022.