Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on June 6, 2022, to July 5, 
2022. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 6, 2022. The NOA was not received by the Plan until December 8, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided on June 6, 2022, to July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) 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 an 
extraction (D7210) provided on February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, of an erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140 x 8), an immediate upper denture (D5130), an immediate lower 
denture (D5140), and the extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth 
(D7210) provided on January 17, 2023. 
 
You asked the Plan to pay for the dental 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 the dental items/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 dental items/services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the items/services provided 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 extractions, of an erupted tooth or exposed root (elevation and/or forceps removal) (D7140 x 8), an 
immediate upper denture (D5130), an immediate lower denture (D5140), and the extraction, of an erupted tooth 
requiring removal of bone and/or sectioning of tooth (D7210) provided on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910), oral hygiene instructions 
(D1330), and nutritional counseling for control of dental disease (D1310) provided on April 19, 2023. 
 
You asked the Plan to pay for the periodontal maintenance, oral hygiene instructions, and nutritional 
counseling for control of dental disease. You say that you were advised at time of service that you would not 
have a copayment for any of the dental procedures. The Plan denied your request. The Plan says these services 
are not covered under your dental 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal 
maintenance (D4910), oral hygiene instructions (D1330), and nutritional counseling for control of dental 
disease (D1310) provided on April 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support and ground 
mileage provided on January 18, 2021. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that you are asking for the 
claim to be reviewed and reprocessed for payment, as this is a result of the enrollee not providing the insurance 
information in a timely manner.  The Plan denied your request. The Plan says the claim was untimely, and the 
submission did not meet the exception criteria guidelines. 
 
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 the ambulance service and ground mileage was not filed until January 17, 
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 ambulance service, advanced life support 
and ground mileage provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says the facet joint 
injections are not medically necessary.   
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 the injections. Our reviewer says that 
the enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee has lumbar 
back pain and multiple other probable pain generators. However, the LCD coverage criteria have not been met. 
Therefore, the request is not 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350) provided on April 4, 2023. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. The Plan denied your request. The Plan 
says this is not a covered benefit 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350) provided on April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for evaluation provided on February 10, 2023. 
 
You asked the Plan to pay for home visit for evaluation. You say that the assisted living facility is responsible 
to obtain prior authorization for all patients. 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 home visit for 
evaluation provided on February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composite - one surface, posterior tooth 
#18 (D2391) provided on March 21, 2023. 
 
You asked the Plan to pay more for the posterior tooth #18. You say that this was the best option to save this 
tooth and was the most stable for this repair. You also say that you would never opt for a more expensive 
treatment as you are unable to pay for major dental work. The Plan denied your request. The Plan says the 
benefit was paid at the least costly method of treatment, and you are responsible for the remaining balance. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes coverage 
for fillings once every 24 months per surface, per tooth.  White filings on posterior teeth will be processed as a silver filling and the enrollee is responsible up to the 
contracted fee. You pay 50% coinsurance for Class 2 Basic services.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage that covers the requested resin-based 
composite - one surface, the Plan processes it as a silver filling and you are responsible up to the contracted fee.  
You are responsible for the difference between the allowed amounts, which is $131 minus the allowed amount 
of $95 = $36.00 for D2391. For the D2140 amalgam-one surface, primary or permanent on tooth #18; the 
allowed amount of $95 minus the 50% (plan paid) = $47.50. Your total responsibility is $36.00 + $47.50 = 
$83.50. 
 
Therefore, we decided that the Plan does not have to pay more for a resin-based composite - one surface, 
posterior tooth #18 (D2391) provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on April 21, 2022, to 
April 27, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you should only have to 
pay $300. 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 $310 
copayment per day for days 1-6 for inpatient hospital stay. Includes inpatient acute, inpatient rehabilitation, 
long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you 
are formally admitted to the hospital with a doctors order. The day before you are discharged is your last 
inpatient day. There were six days. 6 x $310 = $1,860. Therefore, results in the total cost sharing amount of 
$1,860. You have been asked to pay a $310 copayment per day for inpatient hospital stay. This item/service falls within 
the inpatient hospital 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 copayment for inpatient 
hospital stay on April 21, 2022, to April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 13, 
2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that this is supported in the records. 
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 subsequent nursing 
facility care provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve contact lens gas permeable (V2531).  
You asked the Plan to pre-approve contact lens gas permeable (V2531). You say that this is a medical 
necessity. The Plan denied your request. The Plan says rigid gas permeable lenses are not listed as a covered 
benefit. The Plan also says that they are under no obligation to pay for services excluded from coverage. 
 
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 provides a reimbursement for up to $120 towards the purchase of eyeglasses or contact 
lenses. Contact lens gas permeable is not listed as a covered benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that they provide a reimbursement for up to $120 
towards the purchase of eyeglasses or contact lenses. Contact lens gas permeable is not listed as a covered 
benefit. Based on this information, we decided that the Plan's rules for coverage of contact lens gas permeable 
(V2531) have not been met. Therefore, we decided that the Plan does not have to pre-approve contact lens gas 
permeable (V2531).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 3 sensor. You say that the one you have is big and bulky 
and falls out. You also say that you have to go to the hospital because the sensor does not work. The Plan 
denied your request. The Plan says you are requesting a CGM product that does not meet Medicare's definition 
of durable medical equipment (DME) and, therefore, is not in a defined Medicare benefit category. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 
We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle Libre 3 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for disposable contact lenses (S0500) and contact lens fitting 
(92310) provided on August 2, 2022. 
 
You asked the Plan to pay for disposable contact lenses (S0500) and contact lens fitting (92310). You say that 
you paid $170 for contacts, and you still received a bill for $195. The Plan denied your request. The Plan says 
the paid the provider the $200 allowance, which leaves you with a responsibility of $50. The Plan also says that 
the $50 member responsibility was denied for the charge exceeds the allowable ate for the service. 
 
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 a $200 allowance for supplemental eyewear every year. The Plan contract also says 
that members are responsible for all costs over and above the allowance amount. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers a $200 allowance for 
supplemental eyewear every year. The Plan contract also says that members are responsible for all costs over 
and above the allowance amount. Based on this information, we decided that the Plan's rules for coverage of 
disposable contact lenses (S0500) and contact lens fitting (92310disposable contact lenses (S0500) and contact 
lens fitting (92310) have not been met. Therefore, we decided that the Plan does not have to pay for disposable 
contact lenses (S0500) and contact lens fitting (92310) provided on August 2, 2022.  
 
Your complaint about potentially being balanced billed by the provider is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered rugs provided from March 9, 2023, to 
March 16, 2023. 
 
You asked the Plan to pay for the medication. You say that you were not given the option to self-administer 
any medications while in the hospital. The Plan denied your request. The Plan says the medication is not 
covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered rugs provided 
from March 9, 2023, to March 16, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for Computed tomography (CT) provided on 
December 16, 2022. 
 
You asked the Plan to reduce the copayment for Computed tomography (CT). You say that you payed $175 
because that is what your plan says for a freestanding building. You say you should not have to pay another 
$100. 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 $275 
copayment for advanced imaging. 
 
You have been asked to pay a $275 copayment for Computed tomography (CT). This item/service falls within 
the advanced imaging 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 copayment for Computed 
tomography (CT) provided on December 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 26, 
2022, through January 31, 2022. 
 
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 claim is not payable as it was submitted 
untimely. 
 
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 these services was not filed until February 21, 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 the acute inpatient hospital care provided from 
January 26, 2022, through January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation, bitewing x-rays, and 
cleaning (D0120, D0274, D1110) provided on March 8, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 a periodic oral evaluation, bitewing x-rays, 
and cleaning (D0120, D0274, D1110) provided on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, cone beam computed tomography 
(CT) scan, and pulp vitality tests (D0140, D0380, D0460) provided on October 27, 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. This benefit 
does not include cone beam CT scans or pulp vitality tests. The record shows your benefit for the requested 
item or service was exhausted on date of service August 01, 2022 (D0140). Therefore, we decided that the Plan 
does not have to pay for a limited oral evaluation, cone beam computed tomography (CT) scan, and pulp 
vitality tests (D0140, D0380, D0460) provided on October 27, 2022.