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

 
We decided that the Plan does not have to pay for a hearing aid (V5298) purchased on January 15, 2023. 
 
You asked the Plan to pay for a hearing aid (V5298). You say your experience with one of the Plan vendors is 
that the vendor seems to be more concerned with making money than helping with a hearing/health problem. 
The Plan denied your request. The Plan says hearing aids must be purchased through the Plan vendor to be 
covered under the hearing aid services offered by your plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only The Plan rules say that hearing aids purchased outside the Plan's hearing network are not 
covered.  
 
 
  We looked at the file and the Plan's rules. The Plan rules say that hearing aids purchased outside the Plan's 
hearing network are not covered. The record shows that the provider you purchased the hearing aids from are 
not in-network with the Plan. Based on this information, we decided that the Plan's rules for coverage of a 
hearing aid (V5298) have not been met. Therefore, we decided that the Plan does not have to pay for a hearing 
aid (V5298) purchased on January 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral exam (D0150) provided on April 8, 
2023. 
 
You asked the Plan to pay for 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 on date of service March 3, 2022. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral exam (D0150) provided on 
April 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided on March 23, 2022, to October 25, 
2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for office visits. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says as a member of the plan, the enrollee can choose to receive care from out-of-
network providers. However, please not providers that to not contract with the plan are under no obligation to 
treat the enrollee, except in emergency situations. The plan will cover services from either network or out-of-
network providers, as long as the services are covered benefits and are medically necessary. However, if the 
enrollee uses an out-of-network provider, the enrollees share of the costs for their covered services may be 
higher.  
 
 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for office visits provided on March 23, 2022, to 
October 25, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on December 13, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you called and were told two pair per 
year would be covered. The Plan denied your request. The Plan says you received a non-covered item. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 pay for the compression 
stockings identified with code A6530 that were issued on December 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PET scan provided on July 7, 2022, by an OON provider.  
 
You asked the Plan to pay for PET scan. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for PET scan provided on July 7, 2022, by an OON 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), the intraoral 
complete series of radiographic images (D0210) and the 2D photographic images (D0350) provided on April 4, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan should cover the dental services 
because you pay for coverage. The Plan denied your request. The Plan says your benefit for the comprehensive 
oral evaluation and the intraoral complete series of radiographic images has already been exhausted. Also, the 
2D photographic images are 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, certain limitations apply. The record 
shows that the Plan paid for a comprehensive oral evaluation (D0150) and the intraoral complete series of 
radiographic images (D0210) on April 16, 2021; therefore, your benefit for the comprehensive oral evaluation 
and the intraoral complete series of radiographic images was exhausted on the date of service of April 16, 
2021. The 2D photographic images are not covered under the Plans dental benefit. Therefore, we decided that 
the Plan does not have to pay for a comprehensive oral evaluation (D0150), the intraoral complete series of 
radiographic images (D0210) and the 2D photographic images (D0350) provided on April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for progressive lenses (V2781) provided on January 24, 
2023.  
You asked the Plan to reimburse for progressive lenses (V2781). You say that you thought this would be 
covered. The Plan denied your request. The Plan says the Plan does not cover this out-of-network vision care 
service/material. 
 
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 service is provided in-network. 
 
We looked at the file and the Plan's rules. The Plan rules say that you must receive your care from a network 
provider. The record shows you purchased your eyewear from an out-of-network provider. Based on this 
information, we decided that the Plan's rules for coverage of progressive lenses (V2781) have not been met. 
Therefore, we decided that the Plan does not have to reimburse for progressive lenses (V2781) provided on 
January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete maxillary/mandibular dentures (D5110, D5120) 
provided on August 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 26, 2022, on the 
appealed claim. Therefore, we decided that the Plan does not have to pay for complete maxillary/mandibular 
dentures (D5110, D5120) provided on August 26, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail an injectable bisphosphonate first.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical records 
provided and the Medicare-approved major drug compendia there is no indication that the plan's required 
drug(s) would likely be less effective and/or likely have adverse effects for the 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ankle foot orthotics (L1951 x2). 
 
You asked the Plan to pre-approve ankle foot orthotics. You say that the enrollee meets coverage criteria for 
the ankle foot orthotics. 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 the ankle foot orthotics (L1951 
x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on January 24, 
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 a bone 
replacement graft (D7953) provided on January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenetics and cardio hereditary 
genetics test provided on December 14, 2022.  
 
You asked the Plan to pay for the comprehensive pharmacogenetics and cardio hereditary genetics test. You 
say that this testing is medically necessary.  The Plan denied your request. The Plan says a comprehensive 
panel for genotyping of genetic variations that may be linked to reduced/enhanced effect or severe side effects 
of drugs metabolized remains unproven as a screening tool. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter are met. 
 
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 comprehensive pharmacogenetics and 
cardio hereditary genetics test. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found that the reviewed literature indicates that comprehensive panel for genotyping of genetic 
variations that may be linked to reduced/enhanced effect or severe side effects of drugs metabolized remain is 
not a standard screening tool. The clinical value and effectiveness of comprehensive pharmacogenetic testing 
has not been demonstrated. The review has determined that the testing was not medically necessary or 
reasonable and did not meet the coverage criteria. 
 
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 comprehensive pharmacogenetics and cardio hereditary genetics test have 
not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive 
pharmacogenetics and cardio hereditary genetics test provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a AAA auto membership purchased on January 31, 
2023. 
 
You asked the Plan to reimburse for a AAA auto membership . You say that the way it is in the booklet, you 
could apply for AAA reimbursement for membership. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a health education program may be offered as a 
supplemental benefit if it is offered to all enrollees or targeted to groups of enrollees based on a diagnosis of, or 
risk for, a specific disease condition and provides more than written material or a website and go beyond 
content alone to include interaction with an educator or professional.  
 We looked at the file and Medicare rules. The record shows that your reimbursement request is for AAA auto 
membership. Triple AAA membership is a separate membership from the AAA senior driving. Based on this 
information, we decided that Medicare rules for coverage of a AAA auto membership have not been met. 
Therefore, we decided that the Plan does not have to reimburse for a AAA auto membership purchased on 
January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on February 14, 
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 core 
buildup services (D2950) provided on February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for crown - porcelain/ceramic (D2740) provided on 
February 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you do not agree with the billed amount 
you are responsible for. 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. The contract also says that you 
must pay 50% coinsurance after the $100 deductible for Class 3 Major services and may be billed by the out-
of-network provider for any charged amount greater than the payment made by the Plan. 
 
The allowed amount of the covered dental services total $771, resulting in a coinsurance amount of $345, and a 
Plan payment of $345 ($771 - $81 deductible = $690 x 50% = $345), and a Plan payment of $345. 
 
You may also be asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 
 
Although the Plan billed for crown - porcelain fused to predominantly base metal (D2751), the cost is the same 
as crown - porcelain/ceramic (D2740). This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for crown - 
porcelain/ceramic (D2740) provided on February 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital, binaural hearing aid (V5261) provided on March 
16, 2023. 
 
You asked the Plan to pay for a digital, binaural hearing aid (V5261). You say that you must admit that you 
were unaware of your requirement that this device had to be purchased through the Plan vendor. The Plan 
denied your request. The Plan says hearing aids and assessments are only eligible from the Plan vendor. The 
Plan also says that you are responsible for these services. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through a Plan vendor.  
 
 
  We looked at the file and the Plan's rules. The Plan rules say that they cover up to two Plan vendor hearing aids 
every year (one per ear per year). The Plan rules also say that this benefit is limited to the Plan vendor hearing 
aids. The record shows that these hearing aids were purchased by an out-of-network provider. Based on this 
information, we decided that the Plan's rules for coverage of a digital, binaural hearing aid (V5261)  have not 
been met. Therefore, we decided that the Plan does not have to pay for a digital, binaural hearing aid (V5261) 
provided on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prefabricated post and core in addition to crown for tooth #4 
(D2954) provided on June 9, 2022. 
 
You asked the Plan to pay for prefabricated post and core. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
prefabricated post and core in addition to crown for tooth #4 (D2954) provided on June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on February 09, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that you are appealing the claim payment denial. 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 foot orthotics provided 
on February 09, 2022.