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

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided 
on September 20, 2022. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you are unable 
to afford the coinsurance 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 20% 
coinsurance for Medicare Part B Prescription Drugs. 
 
You have been asked to pay 20% coinsurance for a Medicare Part B drug injection. This item/service falls 
within the Medicare Part B Prescription 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. The total coinsurance you owe is $185.71, which is 20% of the 
allowed amount for a Medicare Part B drug injection ($928.54 allowed x 20% = $185.71). Therefore, we 
decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on 
September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve first quarter over-the-counter benefits. 
 
You asked the Plan to pre-approve first quarter over-the-counter benefits. You say that you think this benefit 
allowance should be given to you because you were never made aware of this benefit. The Plan denied your 
request. The Plan says you are limited to one free shipment per quarter. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and first quarter 
over-the-counter benefits is an OTC item. Therefore, we decided that the Plan does not have to pre-approve 
first quarter over-the-counter benefits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) provided April 18, 2023. 
 
You asked the Plan to pay for D2392. You say that it is not your fault that the material used was not covered. 
The Plan denied your request. The Plan says the rendered dental service 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 resin-
based composite (D2392) provided April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the item is necessary. 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 physician order which support medical necessity for the supplies provided 
in this case. 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 pre-approve a portable oxygen 
concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination provided on March 15, 2023. 
 
You asked the Plan to pay for a medical eye examination. You say that you were not aware that the provider 
was out-of-network. 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 medical eye 
examination provided on March 15, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on August 9, 2022. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the medical records 
support the transport was a medical necessity. The Plan denied your request. The Plan says transportation to a 
physicians office is not a covered destination. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport, and ground mileage provided on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) 
provided December 14, 2022. 
 
You asked the Plan to pay for D7953. You say that you needed this dental procedure. The Plan denied your 
request. The Plan says the rendered dental service 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 bone 
replacement graft for ridge preservation (D7953) provided December 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit, and an x-ray provided on 
May 3, 2023. 
 
You asked the Plan to waive the copayment for a specialist visit and an x-ray. You say that you do not 
understand why you had two separate copayments for the same visit. 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 each basic imaging service and a $35 copayment for each in-person specialist visit.  
 
You have been asked to pay a $60 copayment for a specialist visit and an x-ray. This total includes a $25 
copayment for an x-ray and a $35 copayment for a specialist visit. The x-ray falls within the outpatient 
diagnostic tests benefit category. The specialist visit falls within the physician/practitioner services. 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 specialist visit, and an x-ray provided on May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on 
March 14, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015) . You say that you have a charge for 
$35, You also say you want to know why you had to pay a price. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
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 they are a part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules also say that the Plan covers one routine vision 
examination per year. The Plan rules also say Original Medicare does not cover routine eye examinations (eye 
refraction) for eyeglasses/contacts. Based on this information, we decided that the Plan's rules for coverage of a 
determination of refractive state (92015)  have not been met. Therefore, we decided that the Plan does not have 
to pay for a determination of refractive state (92015) provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740), the crown lengthening (D4249), and 
the analgesia (D9230) for tooth #29 provided on February 8, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you have provided all the information 
needed to process the payment for the dental services. The Plan denied your request. The Plan says your annual 
dental maximum benefit for the year 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 $435 for dental services on January 19, 2023. On February 8, 2023, the Plan paid $1,065 
for dental services. For the year of 2023 the Plan paid $1,500 ($435 paid + $1,065 paid) for dental services; 
therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of 
February 8, 2023. Therefore, we decided that the Plan does not have to pay more for a crown (D2740), the 
crown lengthening (D4249), and the analgesia (D9230) for tooth #29 provided on February 8, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 28, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you passed 
out and your care giver called an ambulance so you could be picked up from the floor and examined. You also 
say that you were examined and determined not be hurt and feel the charges should be paid by the plan.  The 
Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 28, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns for teeth #3, #4. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you have a $1,000 annual maximum, any remaining charges are your 
responsibility. Also, if a method of treatment is more costly than is customarily provided, benefits will be paid 
on the least costly method of treatment, and you will be responsible for the remaining balance. 
 
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. Therefore, we decided that the Plan does 
not have to pre-approve crowns for teeth #3, #4.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 8, 2022. 
 You asked the Plan to pay for the lab services. You say that the Plan is responsible for the charges. 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 lab services provided on November 8, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on August 12, 2022. 
 You asked the Plan to pay for the anesthesia services. You say that you would like for the claim to be 
reprocessed. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 10, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services provided on August 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from January 1, 2023, to January 7, 2023. 
 
You asked the Plan to pay for SNF care. You say that you are requesting the claim be reviewed and the 
payment processed. The Plan denied your request. The Plan says the enrollee exhausted the 100-day SNF 
benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  The file shows that the enrollee received 100 days of SNF care during the benefit period from June 29, 2022, 
through November 7, 2022, and January 24, 2023, through January 31, 2023. The Plan has covered 100 days of 
SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for SNF care provided from January 1, 2023, to January 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the paid amount for a surgical extraction (D7210) 
provided March 1, 2023. 
 
You asked the Plan to reimburse the paid amount for D7210. You say that you have not been reimbursed. 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 extractions/surgical/in-network.  
 
You have been asked to pay a $25 copayment for D7210. This item/service falls within the 
extractions/surgical/in-network 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 reimburse the paid amount 
for a surgical extraction (D7210) provided March 1, 2023. 
 
The Plan states that reimbursement was sent on Jun 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the intraoral 
radiographic image (D0220) provided on April 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had an emergency, and the frequency of 
limitation should not apply to the dental services. 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 a limited oral evaluation (D0140) and the intraoral radiographic image (D0220) on 
March 28, 2023; therefore, your benefit for the requested items or services was exhausted on the date of service 
of March 28, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140) and the intraoral radiographic image (D0220) provided on April 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code S8037. 
 
You asked the Plan to pre-approve procedure code S8037. You say that the services are necessary. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S8037 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S8037 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S8037 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve procedure code S8037.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve procedure (64454). 
 
You asked the Plan to pre-approve a genicular nerve procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 genicular nerve procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found genicular nerve ablation is experimental for knee pain. 
 
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 genicular nerve procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve procedure (64454).
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 are legally blind and need more than 
32 one-way trips for medical treatments. The Plan denied your request. The Plan says the record shows you 
have used 29 of the 32 allowed trips. 
 
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. 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 pay for a comprehensive oral evaluation (D0150), intraoral 
radiographic images (D0210), an adult prophylaxis (D1110) and the topical application of fluoride varnish 
(D1206) provided on March 7, 2023. 
 
You asked the Plan to pay for a comprehensive oral evaluation (D0150), intraoral radiographic images 
(D0210), an adult prophylaxis (D1110) and the topical application of fluoride varnish (D1206). You say that 
you are appealing with supporting records. The Plan denied your request. The Plan says these services are not 
covered services. 
 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 
comprehensive oral evaluation (D0150), intraoral radiographic images (D0210), an adult prophylaxis (D1110) 
and the topical application of fluoride varnish (D1206) provided on March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom 6.  
You asked the Plan to pre-approve a Dexcom 6. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Dexcom 6. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee is maintained on insulin 
therapy. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD 
for a CGM. 
 
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 Dexcom 6 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dexcom 6.