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

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), 
intraoral-periapical first radiographic image (D0220), and the bitewing x-ray (D0270) provided on April 25, 
2023. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided was exhausted on date of service April 3, 2023. Specifically, the 
Plans contract states that a limited oral evaluation, intraoral-periapical x-ray, and bitewing x-rays are covered 
once per calendar. You previously received these services on April 3, 2023, which were paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for the services provided in this case. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), intraoral-
periapical first radiographic image (D0220), and the bitewing x-ray (D0270) provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on August 31, 2022. 
 
You asked the Plan to pay for outpatient surgery. You say that you are requesting reconsideration for the 
service provided. 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 outpatient surgery 
provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on May 02, 2023. 
 
You asked the Plan to pay for a specialist office visit. You say that the enrollee was seen in your office due to 
diabetes and cataract post-operational follow up. 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 specialist office visit 
provided on May 02, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the ultrasound of leg arteries, and the 
ultrasound of arm and leg arteries provided by an in-network provider on February 10, 2023. 
 
You asked the Plan to waive the cost sharing for the ultrasounds. You say that you do not think you should be 
responsible for the copayment. 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 in and out-of-network deductible which applies to ultrasounds, 
and that you must pay a 4% coinsurance for in and out-of-network Medicare-covered radiological diagnostic 
services, including ultrasounds. 
 You have been asked to pay a $150 deductible for the ultrasound of leg arteries. You have been asked to pay a 
$2.66 coinsurance for the ultrasound of leg arteries ($216.43 allowed amount - $150 deductible = $66.43) 
($66.43 x .04 = $2.66 rounded up). You have also been asked to pay a $2.33 coinsurance for the ultrasound of 
arm and leg arteries ($58.32 allowed amount x .04 = $2.33). The items or services you asked the Plan to waive 
the cost sharing for fall within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 in and 
out-of-network deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. 
This cost sharing is a contractual obligation that had not been met at the time the ultrasounds were provided on 
February 10, 2023. Therefore, we decided that the Plan does not have to waive the cost sharing for the 
ultrasound of leg arteries, and the ultrasound of arm and leg arteries provided by an in-network provider on 
February 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the semi-electric hospital bed provided on April 11, 2023. 
 
You asked the Plan to pay for the semi-electric hospital bed. 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 semi-electric 
hospital bed provided on April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the diabetic footwear (A5500RT, A5500LT, A5512RT, and A5512LT) 
provided on March 20, 2023. 
 
You asked the Plan to pay for the diabetic footwear. You say that the diabetic footwear were medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the provider did not obtain prior 
authorization and the services were not a medical emergency. The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 pay for the diabetic footwear. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the medical documentation supports that this enrollee has diabetes. The medical 
documentation supports negative sensation to all digits bilaterally with positive callous formation plantar feet, 
swelling of feet, and dryness of feet. These are all risk factors that put the enrollee's foot in jeopardy without 
exceptional fitting shoe wear and exceptional foot care.   
 
Medicare advises that they indeed pay for items or services that are medically reasonable or necessary for the 
diagnosis or treatment of an illness or injury. The treatment must be safe and effective, not mainly for the 
convenience of the enrollee or the physician, not experimental or investigational, appropriate in that it is 
furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the 
enrollee's condition, one that meets but does not exceed the enrollee's medical needs, and at least as beneficial 
as existing and available medically appropriate alternatives.  
 
In this particular case the enrollee is noted to have diabetes with risk factors including neuropathy. A diabetic 
enrollee with neuropathy and callous formation should be in a pair of diabetic extra depth shoes with a diabetic 
type of insole. Therefore, it is my opinion that the requested diabetic footwear and inserts are medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the diabetic footwear have been met. Therefore, we decided that the Plan has to 
pay for the diabetic footwear (A5500RT, A5500LT, A5512RT, and A5512LT) provided on March 20, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on April 28, 2023. 
 
You asked the Plan to pay for the chest x-ray. You say that you are appealing the denial with supporting 
documentation. 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 chest x-ray provided 
on April 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 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 72 one-way transportation trips when each one-way trip does not exceed 50 miles. 
 
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 mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on  April 17, 
2023. 
 
You asked the Plan to pay for the oral hygiene instructions. You say that the explanation of payment shows 
D1330 for dentist's charge is $147, resulting in a rejection of claim. The Plan denied your request. The Plan 
says this service is not covered under your 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral 
hygiene instructions (D1330) provided on  April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction and dental consultation (D7210, D9310) 
provided on June 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 dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an extraction and dental consultation (D7210, D9310) provided on June 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 13, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary, we do not need a 
referral for this service. 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 laboratory services 
provided on April 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart system (0408T). 
 
You asked the Plan to pre-approve an Optimizer Smart system. 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 an Optimizer Smart system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, cardiac contractility 
modulation (CCM) remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, the CCM 
system would not be considered medically necessary in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Optimizer Smart system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Optimizer Smart system (0408T).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 3, 2023, to May 
31, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan must follow Medicare rules. The rules say the HHA enters a date of admission matching the From 
date on the first period of care in an admission. On subsequent periods of care, the HHA continues to submit 
the admission date reported on the first period of care.  
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the required 
data element, admission/start of care date on the subsequent period of care claim does not match the admission 
date reported on the first period of care NOA claim. Based on this information, we find that the Medicare rules 
for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay 
for the home health services provided from May 3, 2023, to May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that the shower chair is medically necessary 
because you are unable to shower without assistance. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive, diagnostic hearing test 
(92557) provided on May 11, 2023. 
 
You asked the Plan to waive the copayment for a comprehensive, diagnostic hearing test (92557). You say that 
you received a bill for $15 for what you thought was a routine hearing test. You also say you were not provided 
any information at the visit that this was going to be a diagnostic hearing examination. 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 $15 
copayment for a Medicare-covered diagnostic hearing examination. 
 
You have been asked to pay a $15 copayment for a comprehensive, diagnostic hearing test (92557). This item/service falls within the a Medicare-covered diagnostic hearing examination 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 comprehensive, diagnostic hearing test (92557) provided on May 
11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopic retrograde cholangiopancreatography 
(ERCP). 
 
You asked the Plan to pre-approve ERCP. 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 ERCP. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found documentation does not support that ERCP is medically necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ERCP have not been met. Therefore, we decided that the Plan does not have to 
pre-approve endoscopic retrograde cholangiopancreatography (ERCP).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on January 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 G0483 is Drug Testing, Definitive. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the lab order did not specify 
which tests were to be performed. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(G0483) provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment  includes placement tooth 
29, 30 (D6057) and abutment supported porcelain/ceramic crown tooth 29, 30 (D6058). 
 
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 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. Therefore, we decided that the Plan does 
not have to pre-approve custom fabricated abutment  includes placement tooth 29, 30 (D6057) and abutment supported porcelain/ceramic crown tooth 29, 30 (D6058).