Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on July 19, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this was medically necessary and should be covered. 
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 facility visit provided 
on July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a quantity of 200 per 90 days of Freestyle Lite
test strips.

You asked the Plan to provide coverage for a quantity of 200 per 90 days of Freestyle Lite test strips. The Plan
denied your request. The Plan says this quantity exceeds the Medicare allowed quantity for non-insulin
dependent enrollees. Maximus overturned the Plans denial. The Plan requested a reopen and noted that
Maximus did not apply the correct criteria.

The Plan must follow Medicare rules. Medicare has specific coverage criteria for exceptions to the quantity
limit for test strips. Based on the medical records provided, you do not meet those criteria. Therefore, we
decided that the Plan does not have to provide coverage for a quantity of 200 per 90 days of Freestyle Lite test
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on June 15, 2023. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a preventative screening. 
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 $290 
copayment for in-network outpatient surgery including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $290 copayment for a colonoscopy. This item/service falls within the in-network 
outpatient surgery including services provided at hospital outpatient facilities 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 record shows this was a diagnostic 
colonoscopy. Therefore, we decided that the Plan does not have to waive the copayment for a colonoscopy 
provided on June 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics and office visit (L3000, 99203) provided on 
June 27, 2023. 
 
You asked the Plan to pay for foot orthotics. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. 
. 
You have been asked to pay a $30 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office 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 pay for 
foot orthotics and office visit (L3000, 99203) provided on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for core buildup, pontic, and retainer crowns (D6750, 
D6740, D6245, D2950) provided on June 12, 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 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 June 12, 2023. Therefore, 
we decided that the Plan does not have to pay more for core buildup, pontic, and retainer crowns (D6750, 
D6740, D6245, D2950) provided on June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a walker provided on June 21, 2023. 
 
You asked the Plan to waive the coinsurance for a walker. You say that you were not told that you would have 
a cost share. 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-covered durable medical equipment. 
 
You have been asked to pay 20% coinsurance for a walker. This item/service falls within the Medicare-covered 
durable medical equipment 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 you owe is $10.69 ($53.44 allowed amount x 20% = $10.69 rounded up). Therefore, we decided that the Plan does not have to waive the coinsurance for a walker provided on June 21, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87798, 87500, and 
87641 provided on August 18, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. Review of the file shows that the services rendered were unbundled 
and billed as individual components. Based on this information, we decided that Medicare rules for coverage of 
the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services billed with codes 87798, 87500, and 87641 provided on August 18, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure provided on June 26, 2023, to July 03, 
2023. 
 
You asked the Plan to pay for therapeutic procedure. You say that you strongly believe your physical therapy 
bill was denied unjustifiably. 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 therapeutic procedure 
provided on June 26, 2023, to July 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper and lower full dentures rendered on February 22,
2023.

You asked the Plan to pay for the dental services. You say that you needed new dentures because you didn't
like your old ones. 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 Plan's coverage rules apply in this case. The Plan covers upper and
lower full dentures once every 60 months.

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The previous
determination stated that the Plan had to pay for the services because the correct Evidence of Coverage (EOC)
was not received; however, the Plan Dental Rider with the correct coverage information was included in the
original case submission. The record shows your benefit for the full upper and lower dentures was exhausted
on February 8, 2023. Therefore, we decided that the Plan does not have to pay for the upper and lower full
dentures rendered on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0220, D0230) provided on July 12, 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 intraoral 
x-rays (D0220, D0230) provided on July 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
testing (87486, 87541, 87581, 87631, 87651, 87798) provided on March 1, 2023. 
 
You asked the Plan to pay for the respiratory PCR panel testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory panels for more than 5 pathogens are 
not covered. 
 
We looked at the file and Medicare rules. In this case the panel at issue tested for more than 5 respiratory 
pathogens. Based on this information, we decided that Medicare rules for coverage of the respiratory PCR 
panel testing have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory 
polymerase chain reaction (PCR) panel testing (87486, 87541, 87581, 87631, 87651, 87798) provided on 
March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional trips. You say that you urgently require more trips because you 
are in poor health and have several medical appointments which require the additional transportation service. 
The Plan denied your request. The Plan says the evidence shows you have used thirty-four (34) one-way trips 
this year 2023.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 34 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional trips for your medical appointments. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional routine transportation trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5225). 
 
You asked the Plan to pre-approve the dental service. You say that you had a tooth removed and you cannot 
use the previous denture, so you need a new partial. 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 the Plan paid for a partial upper denture (D5225) on July 2, 2022; therefore, your benefit for the 
requested item or service was exhausted on the date of service of July 2, 2022. Therefore, we decided that the 
Plan does not have to pre-approve a partial upper denture (D5225).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6452. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are not happy with the denial 
of authorization for the stockings. The Plan denied your request. The Plan says this item is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6452 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6452.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210) provided on August 8, 2023. 
 
You asked the Plan to pay for the intraoral  comprehensive series of radiographic images. You say that you 
went to the dental office to have a tooth pulled and the process was an exam first with an x-ray. You also say 
that they had your insurance card and you were never told that would be any cost due from you. The Plan 
denied your request. The Plan says your benefit for the requested 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 service was exhausted on date of service August 12, 2021. Therefore, we 
decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210) provided on August 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core (D2954) for tooth #21. 
 
You asked the Plan to pre-approve the dental service. You say that the requested dental service is medically 
necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the prefabricated post and core 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 pre-approve a 
prefabricated post and core (D2954) for tooth #21.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided January 17, 2022, to January 
25, 2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this claim 
was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until March 14, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided January 17, 2022, to January 25, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve more for a complete upper denture (D5110) and a 
partial lower denture (D5214) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve more for the dental services. You say that there are no in-network providers 
that are willing to do the work and you should be able to go outside of the network. 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 pre-approve more for a complete upper denture (D5110) 
and a partial lower denture (D5214) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that the requested orthotics are medically necessary 
and would help your balance. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips to see your 
orthopedist. The Plan denied your request. The Plan says the evidence shows you have used thirty-two (32) 
one-way trips this year 2023. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 32 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional trips for orthopedist appointments. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental service. You say that you were told that you received a partial 
denture in June of 2023, but you never received 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 the Plan paid for a partial upper denture (D5213) on June 13, 2022; therefore, your benefit for the 
requested item or service was exhausted on the date of service of June 13, 2022. Therefore, we decided that the 
Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you need a CGM. The Plan denied your request. The 
Plan says the medical criteria for a CGM has not been met. 
 
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. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).