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

 
We decided that the Plan does not have to pre-approve a pneumatic compressor and a pneumatic appliance to 
be provided by an OON provider.  
 
You asked the Plan to pre-approve a pneumatic compressor and a pneumatic appliance. You say that you are 
requesting reconsideration of the denied items. The Plan denied your request. The Plan says the items were not 
approved. 
 
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 pneumatic compressor and a pneumatic appliance to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthodontic retention (removal of appliances, 
construction and placement of retainer(s)) (D8680) provided on September 21, 2023. 
 
You asked the Plan to pay for this dental 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 covered 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 service provided is not among 
those covered under this benefit.  
  
 
 
 
Therefore, we decided that the Plan does not have to pay for the orthodontic retention (removal of appliances, 
construction and placement of retainer(s)) (D8680) provided on September 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays, an interim partial denture, and extraction 
(D7140, D0220, D5820) provided on June 22, 2023, to July 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for intraoral x-rays, an interim partial denture, and extraction (D7140, D0220, D5820) provided on June 
22, 2023, to July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified preventive procedure (D1999) provided on 
August 17, 2023. 
 
You asked the Plan to pay for unspecified preventive procedure. 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 
unspecified preventive procedure (D1999) provided on August 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye examination, an eye refraction, deluxe frames, 
progressive lenses, and polycarbonate lenses provided on May 2, 2023. 
 
You asked the Plan to pay for a routine eye examination, an eye refraction, deluxe frames, progressive lenses, 
and polycarbonate lenses. You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says the claim was from a provider who is not in the network. The Plan also says that the 
benefit Plan does not cover this out-of-network vision care. 
 
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 vision services when you obtain them from an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one routine eye examination per 
year, and provide an allowance toward your eyeglasses. The Plan rules also say that you must use a network 
provider for all your services. Based on this information, we decided that the Plan's rules for coverage of a 
routine eye examination, an eye refraction, deluxe frames, progressive lenses, and polycarbonate lenses have 
not been met. Therefore, we decided that the Plan does not have to pay for a routine eye examination, an eye 
refraction, deluxe frames, progressive lenses, and polycarbonate lenses provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical first x-ray (D0220) and a cone beam computed 
tomography capture (D0364) provided on June 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were to understand this was a covered 
expense and no out-of-pocket as you were below your $2,000 limit. You also say that this office also took and 
billed you for additional x-rays even though they were already sent over by the primary dentist. 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 periapical first x-ray (D0220) was exhausted on date of service June 19, 2023.  A cone 
beam computed tomography capture (D0364) is excluded from this benefit. Therefore, we decided that the Plan 
does not have to pay for periapical first x-ray (D0220) and a cone beam computed tomography capture (D0364) 
provided on June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate maxillary denture (D5130) and immediate 
mandibular denture (D5140) provided on August 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you need dentures to be able to eat. You also 
say that all your other teeth have been already gone. 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 20, 2021. 
Therefore, we decided that the Plan does not have to pay for immediate maxillary denture (D5130) and 
immediate mandibular denture (D5140) provided on August 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided on May 
18, 2023. 
 
You asked the Plan to pay for the FoundationOne CDx testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS testing is covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. The enrollee's records do not show that the enrollee has advanced, 
metastatic, recurrent, and refractory cancer. Based on this information, we decided that Medicare rules for 
coverage of the FoundationOne CDx testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the FoundationOne CDx testing (0037U) provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) and intraoral-periapical each additional 
radiographic image (D0230) provided on July 8, 2023, and July 15, 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 intraoral-periapical each additional radiographic image has already 
been exhausted. A core buildup 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, certain limitations apply. The record 
shows your benefit for the intraoral-periapical each additional radiographic image was exhausted on date of service July 8, 2023, and July 15, 2023. Therefore, we decided that the Plan does not have to pay for core 
buildup (D2950) and intraoral-periapical each additional radiographic image (D0230) provided on July 8, 2023, 
and July 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on May 1, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 dental services provided on May 1, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 7, 2023, though 
April 13, 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 that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was evaluated in the emergency department (ED) on April 7, 2023 and was admitted 
with a diagnosis of syncope. She was evaluated with serial electrocardiograms and monitoring and underwent a 
transesophageal echocardiogram. She was also evaluated by physical and occupational therapy. Her condition 
stabilized and improved and she was discharged to a skilled nursing facility on April 13, 2023 when considered 
medically stable. The review has determined that the record showed that at the time of the inpatient admission 
it was reasonable for the admitting physician to expect that the enrollees necessary hospital care (including 
earlier ED and/or observation care) would span two midnights with supporting documentation of the enrollees 
history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from April 7, 2023, though April 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the cataract surgery, and the phenylep 
ketorolac injection provided on February 20, 2023. 
 
You asked the Plan to waive the cost share for the cataract surgery and the injection. You say that you were 
unaware of the cost share. 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 $100 
copayment for each Medicare-covered ambulatory surgical center visit. Your contract with the Plan also clearly 
says that you must pay 20% coinsurance for Medicare-covered Part B drugs. You have been asked to pay a $100 copayment for the cataract. This item/service falls within the outpatient 
surgery, including services provided at ambulatory surgical centers 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.  
 
You have also been asked to pay $77.58, which is 20% coinsurance of the allowed amount for the injection 
($387.88 allowed amount x 20% = $77.58). This item/service falls within Medicare Part B prescription drugs 
benefit category. The total amount you have been asked to pay is $177.58 ($100 copayment + $77.58 
coinsurance = $177.58). 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 cataract surgery, and the 
phenylep ketorolac injection provided on February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on July 18, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 the nursing facility care provided on July 18, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal and chest x-ray provided on May 01, 2023. 
 
You asked the Plan to pay for the abdominal and chest x-ray. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the abdominal and chest 
x-ray provided on May 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97813, 97814) and the office 
visit (99201) provided from July 11, 2023, through July 25, 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 are not payable as they were 
rendered by an ineligible provider.  
 
 
 
  
 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97813, 
97814) and the office visit (99201) provided from July 11, 2023, through July 25, 2023.
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 the appointment is necessary. The Plan denied 
your request. The Plan says there is an in-network provider available for this service. 
 
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 pay for intraoral - complete series of radiographic images (D0210), 
interim partial denture (maxillary)(D5820), cone beam CT capture and interpretation with limited field of view 
(D0364) and limited oral evaluation - problem focused (D0140) provided on June 7, 2023, to June 21, 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 intraoral - complete series of radiographic images and the limited 
oral evaluation has already been exhausted. Interim partial denture and a cone beam CT capture and 
interpretation are not covered services. 
 
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 intraoral - complete series of radiographic images and the limited oral evaluation 
was exhausted on date of service May 16, 2023. Therefore, we decided that the Plan does not have to pay for 
intraoral - complete series of radiographic images (D0210), interim partial denture (maxillary)(D5820), cone 
beam CT capture and interpretation with limited field of view (D0364) and limited oral evaluation - problem 
focused (D0140) provided on June 7, 2023, to June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray, pulp vitality tests, endodontic therapy, 
treatment of root canal obstruction, intraorifice barrier, and limited oral evaluation (D3310, D0460, D0220, 
D3331, D3911, D0140) provided on June 13, 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 your benefit for the limited oral evaluation has 
already been exhausted. Prior authorization was not obtained for the intraoral x-ray, pulp vitality tests, 
endodontic therapy, treatment of root canal obstruction. Additionally, intraorifice barriers denied correctly as 
they are not covered by 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, certain limitations apply. The record 
shows your benefit for the limited oral evaluation was exhausted on date of service May 24, 2023 (D0140). 
Prior authorization was not obtained for the intraoral x-ray, pulp vitality tests, endodontic therapy, treatment of 
root canal obstruction. Additionally, intraorifice barriers denied correctly as they are not covered by your dental 
benefits. Therefore, we decided that the Plan does not have to pay for an intraoral x-ray, pulp vitality tests, 
endodontic therapy, treatment of root canal obstruction, intraorifice barrier, and limited oral evaluation (D3310, 
D0460, D0220, D3331, D3911, D0140) provided on June 13, 2023.