Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on June 28, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted all the 
required documents and would like the claim processed. 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 proof of delivery. Specifically, there is no signed receipt of the delivery. 
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 pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0230) and the core 
buildup (D2950) for tooth #7 provided on March 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider told you the services would be 
covered, and you would like the records adjusted so the enrollee does not owe anything. The Plan denied your 
request. The Plan says your benefit for the intraoral radiographic image has already been exhausted. Also, the 
core buildup 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, certain limitations apply. The record 
shows the Plan paid for the intraoral radiographic image (D0220) on March 31, 2023; therefore, the enrollees 
benefit for the intraoral radiographic image was exhausted on the date of service of March 31, 2023. The core 
buildup is not covered under the Plan's dental benefit. Therefore, we decided that the Plan does not have to pay 
for the intraoral radiographic image (D0230) and the core buildup (D2950) for tooth #7 provided on March 31, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant/abutment supported interim fixed maxillary denture 
(D6119) provided on June 7, 2023. 
 
You asked the Plan to pay for D6119. You say that you needed this dental work. The Plan denied your request. 
The Plan says the rendered dental services are not covered 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 
implant/abutment supported interim fixed maxillary denture (D6119) provided on June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
August 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that this dental work was medically necessary. 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 dental services provided by an out-of-network provider on August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
July 20, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239) provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), mechanical traction 
therapy (97012), and the unlisted modality (97039) provided on July 14, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided in this case are not 
covered by Medicare or the Plan.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the therapeutic exercises (97110), mechanical traction therapy (97012), 
and the unlisted modality (97039) provided on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for progressive lenses (V2781) and routine eye 
examination including refraction (S0621) provided on July 19, 2023. 
 
You asked the Plan to reimburse for progressive lenses and routine eye examination including refraction. You 
say that your insurance states you get one pair of eyeglass frames per year. You also say you are enclosing a 
copy of the receipt for this frame. The Plan denied your request. The Plan says this benefit has been exhausted. 
 
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 up to $150 every year for non-Medicare covered prescription eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan pays up to $150 every year for non-
Medicare covered prescription eyewear. You are responsible for any amount above the eyewear coverage limit. 
The record shows this benefit was exhausted on July 28, 2023. Based on this information, we decided that the 
Plan's rules for coverage of progressive lenses and routine eye examination including refraction  have not been 
met. Therefore, we decided that the Plan does not have to reimburse for progressive lenses (V2781) and routine 
eye examination including refraction (S0621) provided on July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment to regions other than 
spine (98943) provided on April 25, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this chiropractic service is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic manipulative treatment to regions other than spine (98943) 
provided on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), and 
panoramic radiographic image (D0330) provided on August 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you went to the provider to get fitted for partials 
but were not able to get them without having additional teeth extracted. The Plan denied your request. The Plan 
says your benefit for the requested 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 your benefit for the limited oral evaluation was exhausted on date of service February 6, 2023, and the 
panoramic radiographic image was exhausted on date of service June 15, 2023. Therefore, we decided that the 
Plan does not have to pay for the limited oral evaluation - problem focused (D0140), and panoramic 
radiographic image (D0330) provided on August 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D9230) on September 5, 2023. 
 
You asked the Plan to pay for the dental service (D9230). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the 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 the dental 
service (D9230) on September 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM), supplies and 
accessories provided on July 4, 2023. 
 
You asked the Plan to pay for the CGM, supplies and accessories. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM), 
supplies and accessories provided on July 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor (99203) on 
September 1, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that the Plan does not want to pay anything 
because the provider used code 99203. The Plan denied your request. The Plan says this chiropractic service is 
excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor (99203) on September 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a periodic oral evaluation (D0120), the 
intraoral radiographic image (D0220), and a cleaning (D1110) provided by an out-of-network provider on 
October 13, 2023. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that it was never mentioned that 
you needed to go to an in-network provider. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. Also, it was verified prior to the date of service you were given the proper information about 
your benefits. 
 
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 20% 
coinsurance for preventive and comprehensive dental services when received by an out-of-network provider. The total allowed amount for the periodic oral evaluation (D0120) was $69 and the total coinsurance was 
$13.80 ($69 allowed x 20% coinsurance). The total allowed amount for the intraoral radiographic image 
(D0220) was $117 and the total coinsurance was $23.40 ($117 allowed x 20% coinsurance). The total allowed 
amount for the cleaning (D1110) was $35 and the total coinsurance amount was $7 ($35 allowed x 20% 
coinsurance). 
 
You have been asked to pay a 20% coinsurance for the dental services. This item/service falls within the dental 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a periodic oral evaluation 
(D0120), the intraoral radiographic image (D0220), and a cleaning (D1110) provided by an out-of-network 
provider on October 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the medical eye examination and evaluation 
with initiation of diagnostic and treatment program (92004) provided on September 5, 2023. 
 
You asked the Plan to waive the cost share for the vision service. You say that your doctor did not do anything 
different from your normal eye exams in the past. 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 $35 
copayment for vision care.  
 
You have been asked to pay a $35 copayment for the vision service. This service falls within the vision care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost share for the medical eye examination and 
evaluation with initiation of diagnostic and treatment program (92004) provided on September 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation provided on February 9, 
2022. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the claim must be filed no 
later than the close of the period ending 1 calendar year after the date of service. 
 
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 psychiatric diagnostic evaluation was not filed until August 1, 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 psychiatric diagnostic evaluation provided on 
February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services provided on August 
10, 2023. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says medical nutrition therapy 
services are covered by Medicare only for diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does 
not have to pre-approve medical nutrition therapy services provided on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 1, 2022. 
 
You asked the Plan to pay for dental services. You say that you needed this dental work. The Plan denied your 
request. The Plan says the enrollee does not have dental benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on 
December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 114, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 September 3, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on September 114, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0140 and D7210) on May 18, 2023. 
 
You asked the Plan to pay for the dental services (D0140 and D7210). You say that you would like to request 
reconsideration for payment. 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 the dental services (D0140 and D7210) on May 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM), supplies and 
accessories provided on July 7, 2023. 
 
You asked the Plan to pay for the CGM, supplies and accessories. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says you have submitted proof of delivery along with other supporting 
documentation, but the claim keeps denying for missing this information. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM), 
supplies and accessories provided on July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions (D7210 x 5) provided on August 24, 
2023. 
 
You asked the Plan to pay for the dental services. You say that these procedures were necessary to prevent 
serious illness or complications from an oral infection. 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 24, 2023. 
Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7210 x 5) provided on 
August 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the home health services. You say that you need these services as you have 
been unable to shower. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 the home health services. Our reviewer 
says that the services are not medically reasonable and necessary.  Our physician reviewer found you are noted to be medically stable. You do not require wound care, 
catheterization, G-tube feeding, or administration of intravenous or complex medications. You have not been 
recently hospitalized. You have impaired mobility and use a power mobility device for assistance in your 
facility. You can independently perform daily activities but do require some assistance with bathing and 
supervision for falls. You live in an assisted living facility and have access to assisted care. Therefore, the 
home health skilled nursing care and home health aide assistance are not 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 the home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.