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

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) or receiver, and 
supply allowance. 
 
You asked the Plan to pre-approve the CGM or receiver, and supply allowance. The Plan denied your request. 
The Plan says after evaluating all the information, the denial for the equipment and supplies requested was 
sustained on appeal. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of the CGM and supply allowance have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor (CGM) or receiver, and supply allowance.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the left total knee arthroplasty (27447) provided on May 16, 
2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the claim is not payable as the provider was 
not certified to render this service. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
  
 
 
 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the left total knee arthroplasty 
(27447) provided on May 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an out-of-network mouth biopsy procedure 
provided on April 17, 2023. 
 
You asked the Plan to waive the deductible for a mouth biopsy. You say that you did not know that this 
provider was out-of-network. Getting this issue taken care of was time sensitive and could have been 
detrimental to your health. You feel you should not have to pay the deductible for these reasons.  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 $750 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to physician/practitioner services, 
including doctors office visits. You have been asked to pay $700 towards this deductible. This cost sharing is a contractual obligation that had not been met at the time a mouth biopsy was received on 
April 17, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an out-of-
network mouth biopsy procedure provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prepackaged meals from Optavia provided on January 1, 
2023. 
 
You asked the Plan to pay for prepackaged meals from Optavia. You say that you believe it should be covered 
under the weight loss reimbursement benefit. The Plan denied your request. The Plan says prepackaged meals 
are not covered under the Plan benefit per your EOC.  
The Plan must follow Medicare rules. Medicare rules say that weight management programs may be offered as 
a supplemental benefit designed to promote healthy behaviors that help an individual to lose weight and keep it 
off, but the program may not offer meals as part of the benefit.  
 
We looked at the file and Medicare rules. Prepackaged meals are excluded from this benefit. Based on this 
information, we decided that Medicare rules for coverage of prepackaged meals from Optavia have not been 
met. Therefore, we decided that the Plan does not have to pay for prepackaged meals from Optavia provided on 
January 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the tint, the anti-reflective coating, the 
progressive lens, and the polycarbonate lens provided on July 17, 2023. 
 
You asked the Plan to pay for the frames, the tint, the anti-reflective coating, the progressive lens, and the 
polycarbonate lens. You say that you have not had a claim for eyeglasses in two years. You say your provider 
is in-network and you want to be reimbursed. The Plan denied your request. The Plan says the benefit has been 
exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when one pair of standard lenses and frame every two years. 
 
We looked at the file and the Plan's rules. Specifically, you received eyeglasses on July 18, 2022, which 
exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the frames, 
the tint, the anti-reflective coating, the progressive lens, and the polycarbonate lens have not been met. 
Therefore, we decided that the Plan does not have to pay for the frames, the tint, the anti-reflective coating, the 
progressive lens, and the polycarbonate lens provided on July 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional panoramic radiographic images and 2D oral/facial 
photographic image (D0350, D0330) provided on June 28, 2023. 
 
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 your benefit for panoramic radiographic images 
has already been exhausted. Coverage for the 2D oral/facial photographic images 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 28, 2023 (D0330). 
Additionally, this benefit does not include 2D oral/facial photographic images. Therefore, we decided that the 
Plan does not have to pay for additional panoramic radiographic images and 2D oral/facial photographic image 
(D0350, D0330) provided on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown and core buildup services (D2950, D2740) 
provided on May 31, 2023. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Coverage for core buildup 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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Moreover, this benefit does not include core buildup services. Therefore, we decided that the Plan does not 
have to pay more for a crown and core buildup services (D2950, D2740) provided on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan (D0367) 
provided on July 6, 2023 . 
 
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 a cone 
beam computed tomography (CT) scan (D0367) provided on July 6, 2023 .
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a multi-axial rotation + active dorsiflexion unit (L5968)
and vertical shock reducing pylon (L5988) for the enrollee.

You asked the Plan to pre-approve a multi-axial rotation + active dorsiflexion unit and vertical shock reducing
pylon. You say that these items are medically necessary. The Plan denied your request. The Plan says that these
items are not medically necessary.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for a multi-axial
rotation + active dorsiflexion unit and vertical shock reducing pylon. Our Medical Director states that the
available clinical documentation in the case file does not support that the requested multi-axial rotation and
active dorsiflexion unit (L5968) and vertical shock reducing pylon (L5988) are/were medically reasonable and
necessary for the enrollee in this case. Our Medical Director found that the enrollee's condition does not meet
criteria for coverage of a multi-axial rotation + active dorsiflexion unit and vertical shock reducing pylon.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a multi-axial rotation + active dorsiflexion unit and vertical shock reducing
pylon have not been met. Therefore, we decided that the Plan does not have to pre-approve a multi-axial
rotation + active dorsiflexion unit (L5968) and vertical shock reducing pylon (L5988) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a harness for upgrade to expandable controller identified 
with code E2377 and two or more power seating system motors identified with code E2311. 
 
You asked the Plan to pre-approve a harness for upgrade to expandable controller identified with code E2377 
and two or more power seating system motors identified with code E2311. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a harness for upgrade to expandable 
controller identified with code E2377 and two or more power seating system motors identified with code 
E2311. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has Parkinson's disease. A group 3 power 
wheelchair has been approved with multiple power options. The enrollee is able to feed himself independently. 
The documentation shows that the enrollee has adequate strength to manage standard power drives. Therefore, 
the enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a harness for upgrade to expandable controller identified with code E2377 and 
two or more power seating system motors identified with code E2311 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a harness for upgrade to expandable controller identified 
with code E2377 and two or more power seating system motors identified with code E2311.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D9215 and D9230) on July 19, 2023. 
 
You asked the Plan to pay for the dental services (D9215 and D9230). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the services are not covered 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 the dental 
services (D9215 and D9230) on July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
August 8, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider.  
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on August 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
August 15, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider.  
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on August 15, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided September 12, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that the claim should be paid. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the inpatient services provided September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan provided on 
August 15, 2023. 
 
You asked the Plan to pay for the CT scan. 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 a cone 
beam computed tomography (CT) scan provided on August 15, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional PT visits are necessary. 
The Plan denied your request. The Plan says you do not meet the criteria for the additional PT visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.  

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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you appear to have improved with therapy to the point of being able to 
manage activities of daily living though still with some pain and difficulty. After the now 16 approved physical 
therapy treatments, records do not support that the complexity of your condition is such that the skills of a 
professional therapist are required to achieve further improvement in your symptoms or functional status. 
Further utilization of the home exercise program appears appropriate at this point. No medical notes from your 
treating physician are provided documenting an order or need for additional skilled therapy services beyond the 
additional services just approved. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 out-of-network routine transportation trips (A0100). 
 You asked the Plan to pre-approve the routine transportation trips. You say that you have used this provider 
under the previous transportation vendor. You also say that you are not satisfied with the service you have 
received with the current transportation vendor. The Plan denied your request. The Plan says per your plan 
benefits you must use network providers to get health care and services when there are network providers 
available. From the records received, no medical need is shown as to why you cannot get this service from a 
provider in your health plan. 
 
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 routine transportation when provided by the Plans designated routine transportation 
vendor. 
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation by an out-of-network provider. This service is only provided by the Plans 
designated routine transportation vendor. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve 14 out-of-network routine transportation trips (A0100).  
 
Your complaint your dissatisfaction with the Plans transportation 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital bed (E0260) purchased on March 9, 2023.

You asked the Plan to pay for this purchase. The Plan denied your request. The Plan says durable medical
equipment can require prior authorization and specific criteria be met prior to approval being given.

Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says
that durable medical equipment requires prior authorization. The Plan did not pre-approve the purchase of this
hospital bed. Therefore, we decided that the Plan does not have to pay for a hospital bed (E0260) purchased on
March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) provided on June 14, 2023.

You asked the Plan to pay more for the dental services. You say that the services should be covered as you disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-sharing amount when your services are received from an out-of-network provider.

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.

You have been asked to pay the difference between the out-of-network provider's charges and the Plan's payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) provided on June 14, 2023.