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

 
We decided that the Plan does not have to pay for a mandibular interim partial denture (D5821) provided on 
May 4, 2023. 
 
You asked the Plan to pay for a mandibular interim partial denture (D5821). You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says this 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 a 
mandibular interim partial denture (D5821) provided on May 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on May 16, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that authorization would not normally 
be obtained for a clinic visit. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a hospital outpatient 
clinic visit provided on May 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3050), (L3060), and (L3510) provided on 
April 3, 2023. 
 
You asked the Plan to pay for the foot orthotics. You say that you developed bursitis on your hip and the 
surgeon recommended you get fitted for arch supports to level your joint. You also say that you went to a foot 
store and the supports have made a difference and you have no pain now. The Plan denied your request. The 
Plan says this is a non-participating provider who is not certified with Medicare on this date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3050), (L3060), and 
(L3510) provided on April 3, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on May 10, 2023, to May 17, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you disagree 
with the copayments applied to the services provided. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for outpatient rehabilitation services.  
You have been asked to pay a $25 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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. The total copayment you owe is $50 for PT services ($25 per visit x 2 visits 
= $50). Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy 
(PT) visit provided on May 10, 2023, to May 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency 
transport and ground mileage provided on November 24, 2022. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that you are requesting 
reconsideration stating please review and reprocess for payment. 
  The Plan denied your request. The Plan says the amount that was paid by the enrollees insurance was greater 
than our allowable amount. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has verified with 
the auto insurance carrier and has confirmed that they have already paid more than the Medicare-allowed 
amount of the claim, which is $702.50. Therefore, we decided that the Plan does not have to pay for the 
ambulance service, basic life support, emergency transport and ground mileage provided on November 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 31, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 17, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on April 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from March 28, 2023, 
to April 17, 2023. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you were unaware of the copayment 
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 a $65 
copayment each day for days 1 to 5 and $0 copayment for days 6 to 90 of each inpatient hospital admission.  
 
 
  You have been asked to pay a $325 copayment for an IRF stay ($65 per day x 5 days = $325). This 
item/service falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an IRF stay provided from March 28, 2023, to April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0481 provided on February 3, 2023. 
 
You asked the Plan to pay for procedure code G0481. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0481 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the record shows that more 
than 14 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0481 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0481 provided on February 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for an in-network lower back, hip, knee, and 
ankle x-ray provided on April 21, 2023. 
 
You asked the Plan to lower the copayment for an in-network lower back, hip, knee, and ankle x-ray. You say 
that you were told that there would only be a $10 copayment for these services. You feel that's all you should 
pay. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You had four different x-rays, resulting in a $120 total copayment ($30 x 4 = $120)  You have been asked to pay a $120 copayment for an in-network lower back, hip, knee, and ankle x-ray. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 lower the copayment for an in-network lower back, hip, knee, and ankle x-ray 
provided on April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration in conjunction with periradicular surgery (D3431 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not covered under the supplemental 
dental policy.  
 
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 dental items are not 
among those covered under this benefit.  
  
 
 
 
 
Therefore, we decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous 
tissue regeneration in conjunction with periradicular surgery (D3431 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cleaning and inspection of removable complete dentures, 
maxillary and mandibular (D9932), and (D9933) provided on May 16, 2023. 
 
You asked the Plan to pay for the cleaning and inspection of removable complete dentures. You say that the 
plan does not pay to have dentures cleaned but they pay for teeth cleaning, and this was your first year check-
up. You also say that the dentures are your teeth and are cheaper. The Plan denied your request. The Plan says 
this procedure is not a benefit under your dental 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cleaning and 
inspection of removable complete dentures, maxillary and mandibular (D9932), and (D9933) provided on May 
16, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services and to pay for 
the self-administered drugs provided through May 24, 2023, to May 27, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services and to pay for the medication. 
You say that it was medically necessary for the doctors to admit you. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. Also, the medication is not covered as a medical benefit under the 
Plan. 
 
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 $110 
copayment for emergency services. 
 
You have been asked to pay a $110 copayment for the emergency room services and the medication. This 
item/service falls within the emergency care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. The 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 waive the copayment for the emergency 
room services and to pay for the self-administered drugs provided through May 24, 2023, to May 27, 2023.  
 
Benefits for the medication may be available under Medicare Part D. The Plan has sent a Part D reimbursement 
form to you to request the Part D covered drug to be covered. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on  
May 2, 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 this service is not payable as the provider is 
not enrolled in the Medicare program.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  
 
 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 
97811) provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body: endosteal 
implants (D6010 x 3). 
 
You asked the Plan to pre-approve these dental services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
supplemental dental policy.  
 
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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical 
placement of an implant body: endosteal implants (D6010 x 3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on May 01, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you do not believe you owe any 
money. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each in-network specialist visit for Medicare-covered services. 
 
You have been asked to pay a $45 copayment for an office visit. This item/service falls within the each in-
network specialist visit for Medicare-covered 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 an office visit provided on May 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of a refractive state (92015) provided from 
May 16, 2023, to May 17, 2023. 
 
You asked the Plan to pay for a determination of refractive state. You say that in the provider's note, it clearly 
states that the visit will serve as my final postoperative appointment. The Plan denied your request. The Plan 
says the benefit maximum has been reached prior to the date of service. 
 
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 the refraction is the first one of the year. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is no coinsurance or copayment for 
refraction up to one service every calendar year. The Plan rules also say that all subsequent refractions are not-
covered. Based on this information, we decided that the Plan's rules for coverage of a determination of 
refractive state have not been met. Therefore, we decided that the Plan does not have to pay for a determination 
of a refractive state (92015) provided from May 16, 2023, to May 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 and supply allowance. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 and supply allowance. The Plan denied your request. 
The Plan says the enrollee does not use insulin and has no history of hypoglycemic episodes. 
 
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 FreeStyle Libre 2 and supply allowance have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle Libre 2 and supply allowance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 09, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on March 09, 2023.