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

 
We decided that the Plan does not have to pre-approve a portable oxygen system. 
 
You asked the Plan to pre-approve a portable oxygen system. The Plan denied your request. The Plan says a 
portable oxygen system is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen system Our reviewer 
says that a portable oxygen system is not medically necessary. Our physician reviewer found that the records 
are lacking details of the enrollees mobility within the home and as to why a portable oxygen concentrator is 
necessary as opposed to portal oxygen tanks. 
 
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 portable oxygen system have not been met.  Therefore, we decided that the 
Plan does not have to pre-approve a portable oxygen system.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve additional acupuncture treatments (97810, 97811).  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that your request exceeds the allowable benefit for 
the services in this case.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plans contract states that 12 routine in-network acupuncture 
visits are covered per year. Your request in this case is for routine acupuncture visits for peripheral autonomic 
neuropathy. The Plan has stated that you have utilized 11 routine acupuncture visits previously. However, the 
Plan has not provided substantive evidence that demonstrates these acupuncture services were previously 
provided and paid for. The Plan has not substantiated their denial; therefore, we must find in your favor. 
Therefore, we decided that the Plan has to pre-approve additional acupuncture treatments (97810, 97811).   
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the home ventilator provided on January 
26, 2023, to March 26, 2023. 
 
You asked the Plan to waive the copayment for the home ventilator. You say that you do not agree with the 
cost share amount. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 40% out-of-network coinsurance. 
 
  The enrollee has been asked to pay a total of  $1,303.71 for the home ventilator.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
January 26, 2023 Home ventilator $1,086.42 40% $434.57 
February 26, 2023 Home ventilator $1,086.42 40% $434.57 
March 26, 2023 Home ventilator $1,086.42 40% $434.57 
TOTAL:    $1,303.71 
 
This item falls within the durable medical equipment (DME) and related supplies benefit category. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for the home ventilator provided on January 26, 2023, to March 26, 
2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental cleaning (D1110), resin-based composite-three surfaces, 
posterior (D2393), resin-based composite-two surfaces, posterior (D2392), and the bitewing x-rays-two 
radiographic images (D0272) provided on May 21, 2023 and June 8, 2023. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says that the dental services provided in this 
case are not payable as they were rendered by an out-of-network dental provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the services provided in this case were denied as they were not 
rendered by a participating plan provider. However, the Plans contract states that dental services may be 
rendered by an in-network or out-of-network provider. For services obtained out-of-network the plan pays up 
to a certain amount, you may be billed by the provider for any amount greater than what the plan pays. The 
Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the 
Plan has to pay for the dental cleaning (D1110), resin-based composite-three surfaces, posterior (D2393), resin-
based composite-two surfaces, posterior (D2392), and the bitewing x-rays-two radiographic images (D0272) 
provided on May 21, 2023 and June 8, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341), maxillary 
partial denture (D5213) and mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve these dental services. 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 pre-approve 
periodontal scaling and root planing (D4341), maxillary partial denture (D5213) and mandibular partial denture 
(D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies billed with code A4239-KX-CG for date of 
service April 26, 2023. 
 
You asked the Plan to pay for the diabetic supplies. You say that you have provided all needed documentation 
to pay this claim. 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, you did not provide a packing slip or any 
evidence of the specific items and codes that were sent to the enrollee. 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 diabetic supplies billed with code A4239-KX-CG for date of service April 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan, laboratory services and a joint 
injection provided on April 26, 2023. 
 
You asked the Plan to waive the copayment for a CT scan, laboratory services and a joint injection. You say 
that you were never advised the procedure would not be covered by the Plan. 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 $160 
copayment for diagnostic radiology services, a $10 copayment for laboratory services and a $290 copayment 
for each ambulatory surgical center visit.  
 
You have been asked to pay $406.45 for a CT scan, laboratory services and a joint injection. This total includes 
a $10 copayment for laboratory services, a $290 copayment for an injection performed at an ambulatory 
surgical center visit, and $106.45, which is less than the standard copayment for a CT scan. The CT and 
laboratory services fall within the outpatient diagnostic tests benefit category. The joint injection falls within 
the outpatient surgery 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 CT scan, 
laboratory services and a joint injection provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the synthetic graft (D7995) provided on May 23, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the synthetic 
graft is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
synthetic graft (D7995) provided on May 23, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network psychologist. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network psychologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported porcelain fused to metal crown 
(high noble metal) (D6059), a custom fabricated abutment-includes placement (D6057), and surgical placement 
of an implant body: endosteal implant (D6010). 
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says you are requesting a reconsideration of the Plan's 
denial. 
 
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 pre-approve an 
abutment supported porcelain fused to metal crown (high noble metal) (D6059), a custom fabricated abutment-
includes placement (D6057), and surgical placement of an implant body: endosteal implant (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5225). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the enrollees benefit for the requested item 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 enrollees benefit for the requested item was exhausted on date of service September 17, 2021. 
Specifically, the Plans contract provides coverage for an upper partial denture once every five years.  
  
 
 
 
 
The enrollee previously received this dental item on September 17, 2021, less than five years prior, which was 
paid for by the Plan. Therefore, the enrollee has exhausted the allowable benefit for the requested dental item in 
this case at this time. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture 
(D5225).
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 it is medically necessary. The Plan denied your 
request. The Plan says medically necessary care is available in network. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a specialist visit, and an injection provided 
on October 12, 2022. 
 
You asked the Plan to reduce the cost share for a specialist visit and an injection. You say that you were 
informed you would only be responsible for a $100 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 (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 and a $15 copayment for each specialist office visit. You have been asked to pay $1,132.44 for a specialist visit and an injection. This total includes $1,117.44, 
which is 20% of the allowed amount for the Medicare Part B drug injection ($5,587.22 allowed x 20% = 
$1,117.44) and a $15 copayment for a specialist visit. The injection falls within the Medicare Part B 
prescription drugs benefit category. The specialist visit falls within the physician/practitioner 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 reduce the cost share for a specialist visit, and an injection provided on 
October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210 x2). 
 
You asked the Plan to pre-approve 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 January 19, 2023, and 
June 26, 2023. Therefore, we decided that the Plan does not have to pre-approve surgical extractions (D7210 
x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasties in conjunction with extractions-four or 
more teeth or tooth spaces, per quadrant (D7310 x 2) provided on March 30, 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 these services are not a covered benefit under 
the supplemental dental policy.  
 
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 services provided are not among 
those covered under this benefit.   
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the alveoloplasties in conjunction with 
extractions-four or more teeth or tooth spaces, per quadrant (D7310 x 2) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polarized lenses (V2762), polycarbonate lenses (V2784) 
progressive lenses (V2781) and frames (V2020) provided on May 4, 2023. 
 
You asked the Plan to pay for polarized lenses (V2762), polycarbonate lenses (V2784) progressive lenses 
(V2781) and frames (V2020). You say that you previously spoke with a Plan vision representative and was told 
that this provider was in-network. The Plan denied your request. The Plan says this was denied because the 
claim was from a provider not in their network. 
 
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 eyewear is obtained through a provider who is in the Plan 
vision vendor network. 
 
We looked at the file and the Plan's rules. The Plan rules say that non-Medicare-covered routine eye exams and 
eyewear must be obtained from a provider in the Plan's vision vendor network. The Plan rules also say that 
services obtained from vendors outside this network are not covered. The record shows that you went to a 
vendor outside the Plan vision network. Based on this information, we decided that the Plan's rules for 
coverage of polarized lenses (V2762), polycarbonate lenses (V2784) progressive lenses (V2781) and frames 
(V2020) have not been met. Therefore, we decided that the Plan does not have to pay for polarized lenses 
(V2762), polycarbonate lenses (V2784) progressive lenses (V2781) and frames (V2020) provided on May 4, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) and a mandibular 
partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that the previous provider made you a 
prosthesis that did not work for you. You also say that you could not use it because it caused an infection in 
your mouth due to the material used. 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 maxillary partial denture (D5225) was exhausted on date of service September 21, 
2020. The record also shows that your benefit for the mandibular partial denture (D5226) was exhausted on 
date of service February 3, 2020. Therefore, we decided that the Plan does not have to pre-approve a maxillary 
partial denture (D5225) and a mandibular partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, of a premolar tooth (excluding final 
restoration) (D3320) provided on May 10, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic 
therapy, of a premolar tooth (excluding final restoration) (D3320) provided on May 10, 2023.