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

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9946). 
 
You asked the Plan to pre-approve an occlusal guard. You say that an occlusal guard is necessary for the 
enrollee to reduce the negative effects of bruxism and to protect the limited remaining dentition. The Plan 
denied your request. The Plan says this service is not covered under the enrollee's benefit package. 
 
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 an 
occlusal guard (D9946).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0364) provided on June 22, 2022. 
 
You asked the Plan to pay for the dental 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 do not fall 
within your 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 dental 
services (D0364) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) provided by 
an out-of-network provider on April 27, 2022. 
 
You asked the Plan to pay for the treatment of root canal obstruction. You say that you are suffering from 
significant tooth pain. The Plan denied your request. The Plan says the rendered dental work 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 the 
treatment of root canal obstruction (D3331) provided by an out-of-network provider on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953) 
provided by a participating provider. 
 
You asked the Plan to pre-approve a bone replacement graft for ridge preservation. You say that you would like 
to continue with treatment. The Plan denied your request. The Plan says the requested dental services are 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 pre-approve a 
bone replacement graft for ridge preservation (D7953) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth visit provided on December 28, 
2021, February 23, 2022, and March 21, 2022. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that you thought these were curtesy 
calls, not billable appointments. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $45 
copayment for Physician/Practitioner services, including doctors office visits.  
 
You have been asked to pay a total of $135 copayment for three telehealth visits ($45 x 3 = $135). A telehealth 
visit falls 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 a telehealth visit provided on 
December 28, 2021, February 23, 2022, and March 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve additional routine transportation services. You say that these additional 
routine transportation trips are necessary for you to reach medical appointments. The Plan denied your request. 
The Plan says the benefit for routine transportation has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says pneumatic compression 
devices are not covered by Medicare for prevention of deep vein thrombosis (DVT). 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Sensor. 
 
You asked the Plan to pre-approve a Dexcom G6 Sensor. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
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 and 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 Dexcom 
G6 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for immunizations on June 23, 2022. 
 
You asked the Plan to waive the deductible for immunizations. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a 100% which applies to Immunizations.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Immunizations. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$5,600 deductible which applies to Immunizations. This cost sharing is a contractual obligation that had not 
been met at the time immunizations was received on June 23, 2022. Therefore, we decided that the Plan does 
not have to waive the deductible for immunizations on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an out-of-network specialist visit provided 
on March 29, 2022. 
 
You asked the Plan to waive the deductible for an out-of-network specialist visit. You say that you do not 
understand this charge or why the Plan isn't paying. The Plan denied your request. The Plan says you were 
charged this cost sharing correctly. You had not yet met your $500 deductible for the year. 
 
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 $500 
deductible for Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay a $135.88 deductible for an out-of-network specialist visit. An out-of-network 
specialist visit falls within the Physician/Practitioner Services, Including Doctor's 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 deductible for an out-of-network specialist visit 
provided on March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network (OON) inpatient hospital 
care provided from January 18, 2022, to January 19, 2022. 
 
You asked the Plan to waive the coinsurance for the OON inpatient care. You say that you were informed that 
the facility was in-network. The Plan denied your request. The Plan says you were charged this cost sharing 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for out-of-network inpatient hospital services.  
 
The file shows that the Plan verified the facility is not a network facility. Therefore, you have been asked to 
pay $5,252, which is 50% of the allowed amount for the OON inpatient care ($10,504 allowed amount x 50% 
coinsurance = $5,252). The OON inpatient care 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 coinsurance for out-of-network (OON) inpatient hospital care provided 
from January 18, 2022, to January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing evaluation test on April 06, 2022. 
 
You asked the Plan to waive the copayment for hearing evaluation test. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $40 
copayment for one annual routine hearing exam. Diagnostic hearing and balance evaluations performed by 
your provider to determine if you need medical treatment are covered as outpatient care when furnished by a 
physician, audiologist, or other qualified provider. 
 
You have been asked to pay a $40 copayment for hearing evaluation test. Hearing evaluation test falls within 
the Hearing services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for hearing evaluation 
test on April 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Swim Spa PlayStream provided on March 1, 
2022. 
 
You asked the Plan to reimburse you for the Swim Spa PlayStream. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says this item is not covered by 
Medicare or the Plan. 
 
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 reimburse you for the Swim Spa PlayStream provided on March 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthroplasty on April 18, 2022, to April 19, 
2022. 
 
You asked the Plan to waive the copayment for arthroplasty. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $350 
copayment for surgery services at outpatient hospital. If you are having surgery in a hospital facility, you 
should check with your provider about whether you will be an inpatient or outpatient. Unless the provider 
writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing 
amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an 
"outpatient." 
 
 
 
 You have been asked to pay a $350 copayment for arthroplasty. Arthroplasty falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for arthroplasty on April 18, 2022, to April 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services provided on June 2, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 office visit services provided on June 2, 2022, 
by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy on May 04, 2022. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $250 
copayment for each Medicare-covered outpatient surgery or procedure at an outpatient hospital facility or 
ambulatory surgical center. If you are having surgery in a hospital facility, you should check with your provider 
about whether you will be an inpatient or outpatient. Unless the provider writes an order to admit you as an 
inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if 
you stay in the hospital overnight, you might still be considered an outpatient. 
 
 
 
 You have been asked to pay a $250 copayment for colonoscopy. Colonoscopy falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for colonoscopy on May 04, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that this power wheelchair is necessary for 
activities outside of your home. The Plan denied your request. The Plan says the criteria for a power wheelchair 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
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 the enrollee meets LTACH criteria. The 
Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's 
medical needs are being met in the current acute setting. 
 
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 more stable and improving and should only require 
short-term additional acute care services that can safely be administered at the current facility until more stable 
and 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. Transfer to the LTACH is not medically necessary 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient procedure provided on April 
27, 2022. 
 
You asked the Plan to waive the copayment for an outpatient procedure. You say that this was a normal office 
visit, not anything else. The Plan denied your request. The Plan says the copayment that was applied was 
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 a $250 
copayment for Medicare covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges applies.  
 
 
 
 You are being charged $109 rather than the full copayment amount of $250 for an outpatient procedure. An 
outpatient procedure falls within the Medicare covered surgery or other services provided to you at an 
outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical 
charges applies 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 outpatient procedure 
provided on April 27, 2022.