Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on July 26, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says durable medical equipment is 
not covered for use outside the home. 
 
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 pay for the durable medical equipment provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you have a new dentist who is willing to 
give you a replacement upper plate but at full cost. You also say that you have been dealing with the dentures 
that don't fit for almost four years. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 2, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
January 8, 2022, to January 23, 2022. 
 
You asked the Plan to waive the copayment for a hospital stay. You say that much of the care provided during 
the stay was substandard. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $335 copayment per day for days 1 to 6 and a $0 copay for days 7 to 90 for inpatient hospital care.  
 
The enrollee has been asked to pay a $335 copayment per day for the first 6 days and $0 for days 7 to 16 for a 
hospital stay ($335 copayment per day x 6 days = $2,010 total copayment). This item/service falls within the 
inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
inpatient hospital stay provided from January 8, 2022, to January 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the diabetic shoes and inserts provided on 
October 19, 2022. 
 
You asked the Plan to waive the deductible for the shoes and inserts. You say that you would like an out-of-
network exception 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. Your 
contract with the Plan says that there is a $490 deductible which applies to out-of-network durable medical 
equipment.  
 
The item or service you asked the Plan to waive the deductible for falls within the durable medical equipment 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $490 
deductible which applies to out-of-network durable medical equipment. This cost sharing is a contractual 
obligation that had not been met at the time the shoes and inserts was received on October 19, 2022. Therefore, 
we decided that the Plan does not have to waive the deductible for the diabetic shoes and inserts provided on 
October 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 2, 2022, to July 
31, 2022. 
 You asked the Plan to pay for the home health services as billed. 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 covered as 
billed. 
 
The Plan follows Medicare rules. The rules say that Home Health Agencies (HHAs) submit a Notice of 
Admission (NOA) at the beginning of an admission and then submit one claim for each 30-day period of care. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
documentation submitted does not include any evidence to support that a NOA was submitted at the beginning 
of the initial 30-day period of care. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from July 2, 2022, to July 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the canal preparation and fitting (D3950) for tooth #8. 
 
You asked the Plan to pre-approve the dental service. You say that you cannot afford this dental procedure and 
would like the Plan to approve it. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because the canal preparation and fitting are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
canal preparation and fitting (D3950) for tooth #8.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre Sensors. 
 
You asked the Plan to pre-approve the Freestyle Libre Sensors. You say that it was previously covered under 
your insurance. You also say that you suffer from hypoglycemia and need the Freestyle Libre Sensors. 
 The Plan denied your request. The Plan says you do  not require insulin three or more times daily. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle 
Libre Sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle 
Libre Sensors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day system. 
 
You asked the Plan to pre-approve the Freestyle Libre 14 Day system. The Plan denied your request. The Plan 
says the enrollee does not require insulin three or more times daily. 
 
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 use insulin with at 
least three daily injections. Based on this information, we decided that Medicare rules for coverage of the 
Freestyle Libre 14 Day system have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 14 Day system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823) and accessories. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the enrollee lives in a 
long-term rehabilitation facility. The Plan denied your request. The Plan says the requested items are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
The records show that the power wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (K0823) and 
accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve the Freestyle Lite test strips. You say that you are appealing the denied 
service. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
  We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Freestyle Lite test strips. Therefore, we decided that the Plan does not have to pre-approve Freestyle 
Lite test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown - porcelain fused to high 
noble alloys tooth #29 (D6066), and custom fabricated abutment  includes placement tooth #29 (D6057). 
 
You asked the Plan to pre-approve the dental services. You say that you were approved for two implants and 
do not have the money to complete the dental work. The Plan denied your request. The Plan says your benefit 
for the implant supported crown tooth #29 (D6066) , and custom fabricated abutment tooth #29 (D6057) has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the implant supported crown tooth #29 (D6066), and custom fabricated abutment tooth 
#29 (D6057) was exhausted on this claim due to two units already approved.  
 Therefore, we decided that the Plan does not have to pre-approve an implant supported crown - porcelain fused 
to high noble alloys tooth #29 (D6066), and custom fabricated abutment  includes placement tooth #29 
(D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal orthotic device, by report (D7880). 
 
You asked the Plan to pre-approve the occlusal orthotic device. The Plan denied your request. The Plan says 
this service is not covered under the 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 orthotic device, by report (D7880).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the canal preparation and fitting (D3950) for tooth #9. 
 
You asked the Plan to pre-approve the dental service. You say that you have requested the dental service 2 
times and you would like for it to be approved. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the canal preparation and fitting are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
canal preparation and fitting (D3950) for tooth #9.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an in-network screening colonoscopy provided on 
September 20, 2022.   
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you went for a routine 
colonoscopy and did not have any polyps removed. The Plan denied your request. The Plan says that this cost 
sharing was charged correctly. 
 
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 enrollees must pay a $0 copayment for colorectal cancer screening. 
 
The Plan says you must pay a $175 copayment for a screening colonoscopy. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for a screening colonoscopy. The colonoscopy 
at issue was billed with code G0105, a colorectal cancer screening code. Therefore, we decided that the Plan 
has to waive the copayment for an in-network screening colonoscopy provided on September 20, 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 pre-approve surgical dental extractions. 
 
You asked the Plan to pre-approve the surgical extractions. You say that you called the dental benefits 
administrator and were told this was covered at 50% for extractions. The Plan denied your request. The Plan 
says that surgical teeth extractions are not covered under your dental 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 pre-approve 
surgical dental extractions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture-maxillary (D5110) and a complete 
denture-mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures do not fit correctly and are 
uncomfortable. You say you are unable to use the dentures. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 2, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture-maxillary (D5110) and a 
complete denture-mandibular (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are appealing this denial. The Plan 
denied your request. The Plan says there is no documentation that all the criteria has been met. 
 
 The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 SSBCI benefits have been met. 
Specifically, medical records were requested, but not received. Therefore, we decided that the Plan does not 
have to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatments (98943) 
and the office visit (99203) provided from October 31, 2022, through November 16, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the extraspinal chiropractic manipulative treatments (98943) and the 
office visit (99203) provided from October 31, 2022, through November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479 provided on October 24, 2022. 
 
You asked the Plan to pay for procedure code 81479. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 27, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 81479 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 81479 provided on October 24, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic tooth #30 (D6245). 
 
You asked the Plan to pre-approve the pontic - porcelain/ceramic tooth #30 (D6245). The Plan denied your 
request. The Plan says these services are not covered under the 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 a 
pontic - porcelain/ceramic tooth #30 (D6245).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 6, 2022 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that it was 
medically necessary to get assistance. You also say the transport to the hospital was not needed as you just 
needed assistance getting up from the floor. The Plan denied your request. The Plan says these services are not 
a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 6, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 6, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 7, 2022, billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, and 81294. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 7, 2022, billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, and 81294.