Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for chemotherapy injections and radiation 
therapy provided from March 21, 2023, to March 23, 2023. 
 
You asked the Plan to reduce the coinsurance for chemotherapy injections and radiation therapy. You say that 
you disagree with the cost share applied for the chemotherapy treatment. 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 Medicare Part B drugs and 20% coinsurance for radiation therapy.  You have been asked to pay $1,121.98 for chemotherapy injections and radiation therapy. This total includes 
$846.98 for chemotherapy injections ($2,117.44 x 20% = $423.49 per injection x 2 injections = $846.98) and 
$275 for radiation therapy, which is less than the standard amount. This item/service falls within the Medicare 
Part B drugs 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 reduce the coinsurance for chemotherapy injections 
and radiation therapy provided from March 21, 2023, to March 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from December 2, 
2022, to December 21, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that your daughter was advised by the 
facility that no out-of-pocket costs would be applied. 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 $0 
copayment per day for days 1 to 20 and a $150 copayment per day for days 21 to 100 for SNF care.  
 
You have been asked to pay $2,426.20 for a SNF stay. This amount is less than the standard copayment for a 
SNF stay because your maximum out-of-pocket was met with the processing of this claim. This item/service 
falls within the SNF care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay 
provided from December 2, 2022, to December 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs acute rehab to learn how to use 
the walker with one foot to be able to move around on their own after ankle surgery. The Plan denied your 
request. The Plan says the enrollee does not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) provided on February 1, 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 an 
extraction (D7140) provided on February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal tooth #29 
(D2750). 
 
You asked the Plan to pre-approve the crown  porcelain. The Plan denied your request. The Plan says your 
benefit for the crown - porcelain 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 service was exhausted on date of service January 31, 2020. Therefore, we 
decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal tooth #29 
(D2750).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost for an MRI provided on January 26, 2023. 
 
You asked the Plan to reduce the cost for an MRI. You say that you should only pay 4% of what the Plan paid 
for the MRI. 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 $150 deductible which applies to Medicare-covered radiological 
diagnostic services, not including x-rays.  
 
 
  You have been asked to pay $150.57 for an MRI. This total includes a $150 deductible and $0.57 coinsurance, 
which is 4% of the amount after the deductible was applied ($164.24 allowed - $150 deductible = $14.24 
remaining x 4% = $0.57). The item or service you asked the Plan to reduce the cost for falls within the 
outpatient diagnostic tests benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $150 deductible which applies to Medicare-covered radiological diagnostic services, not 
including x-rays. This cost sharing is a contractual obligation that had not been met at the time an MRI was 
received on January 26, 2023. Therefore, we decided that the Plan does not have to reduce the cost for an MRI 
provided on January 26, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from April 12, 2023, to 
April 13, 2023. 
 
You asked the Plan to pay for the medication. You say that you were not allowed to bring your own medication 
to the hospital. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from April 12, 2023, to April 13, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5211), and mandibular partial 
denture (D5212) provided on April 12, 2023. 
 
You asked the Plan to pay for the partial dentures. You say that the previous dentures were lost  on or around 
April 2, 2023. You also say that they went to the dentist on April 12, 2023 to have new dentures made. The 
Plan denied your request. The Plan says you have not satisfied the waiting period for this service. 
 
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 services do not meet the 
Plan's rules for coverage. Therefore, we decided that the Plan does not have to pay for a maxillary partial 
denture (D5211), and mandibular partial denture (D5212) provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0367) provided on March 27, 2023. 
 
You asked the Plan to pay for the dental service. You say that the procedure is necessary to establish a 
diagnosis of your oral condition. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the cone beam is 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 pay for a cone 
beam (D0367) provided on March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on January 23, 2023. 
 
You asked the Plan to pay for hearing aids. You say that there was no way you could afford the cost from the 
Plan hearing vendor. The Plan denied your request. The Plan says the provider who performed these services is 
not in the Plan network. The Plan contract also says that while you are a member of the Plan, you must use 
network providers to receive your medical care and services. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are obtained in-network.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules say that you may receive one hearing aid per ear, per 
calendar year from any network hearing aid provider. The Plan rules also say any fees for any services rendered 
by a non-network hearing aid provider are excluded from this benefit. The record shows that your hearing aids 
were obtained through a provider who is out-of-network. Based on this information, we decided that the Plan's 
rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay 
for hearing aids provided on January 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) and supplies (K0553) 
provided on May 19, 2022. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain a valid proof of delivery to support medical necessity for the supplies provided in 
this case. The delivery date does not match the date of service on the claim. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for continuous glucose monitor (CGM) and supplies (K0553) provided on May 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive periodontal evaluation - new or 
established patient (D0180) provided on March 22, 2023. 
 
You asked the Plan to pay more for the comprehensive periodontal evaluation. You say that you thought the 
dentist was in-network when you were informed this by your referring periodontist. 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.  
 
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. Therefore, we decided that the Plan does not have to pay more for a comprehensive periodontal evaluation - 
new or established patient (D0180) provided on March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair and accessories. 
 
You asked the Plan to pre-approve power wheelchair and accessories. You say that you would like 
reconsideration because the requested power wheelchair and accessories are medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
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 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and the panoramic 
radiographic image (D0330) provided on April 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you did not have a complete series of x-rays so 
the x-ray should be covered. The Plan denied your request. The Plan says your benefit for the requested items 
or services 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 the Plan paid for the intraoral complete series of radiographic images (D0210) on May 4, 2022; 
therefore, your benefit for the panoramic radiographic image (D0330) was exhausted on the date of service of 
May 4, 2022. The record also shows that the Plan paid  for the limited oral evaluation (D0140) on April 24, 
2023; therefore, your benefit for the comprehensive oral evaluation (D0150) was exhausted on the date of 
service of April 24, 2023. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150) and the panoramic radiographic image (D0330) provided on April 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you have concerns about currently needed wound 
care. The Plan denied your request. The Plan says your records did not indicate meeting the Plans coverage 
criteria for admission to a Skilled Nursing Facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for inpatient hospital care provided from  
February 4, 2023, to February 11, 2023. 
 
You asked the Plan to reimburse you for inpatient hospital care. You say that you have provided the medical 
records. The Plan denied your request. The Plan says reimbursement of worldwide benefits requires the 
submission of medical records for emergency or urgent care. The claim was submitted without medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 inpatient hospital care have been met. There are no medical records provided in English. Therefore, we decided that the Plan does not have to 
reimburse you for inpatient hospital care provided from February 4, 2023, to February 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on March 27, 2023. 
 
You asked the Plan to pay for hearing aids. You say that you told the Plan that the Plan provider they sent to 
you had obscene prices. You also say that the Plan only presented you with one provider in your area. The Plan 
denied your request. The Plan says members will receive a negotiated plan discount on hearing aids if they 
purchase hearing aids from their preferred vender. 
 
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 hearing aids are obtained through a Plan hearing vendor.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules say that appointments must be scheduled through the 
Plan hearing vendor. The Plan rules also say you are responsible for any amount over the hearing aid coverage 
limit. The record shows you went to a provider without making the appointment through the Plan hearing 
vendor, and that you went out-of-network. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids provided on March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on March 30, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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.  
 
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. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft (D7953 x4) provided on April 7, 
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 bone 
replacement graft (D7953 x4) provided on April 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intra-oral x-ray (D0210) provided on May 3, 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 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 January 5, 2022. 
Therefore, we decided that the Plan does not have to pay for an intra-oral x-ray (D0210) provided on May 3, 
2023.