Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on December 13, 2022, by an out-
of-network (OON) provider.  
 
 You asked the Plan to pay for rest home visit. You say that you are asking for the attached medical records to 
be reviewed. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 rest home visit provided on December 13, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transport chair provided on February 22, 2023. 
 
You asked the Plan to pay for a transport chair. You say that you believe that this item should be covered. 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 a transport chair 
provided on February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth specialist visit provided on 
December 08, 2022. 
 
You asked the Plan to waive the copayment for the telehealth specialist visit. You say that this was just a 
telehealth consultation. 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 $50 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $50 copayment for the telehealth specialist visit. This item/service falls within 
the in-network specialist 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. The specialist office visit copayment applies to telehealth 
services. Therefore, we decided that the Plan does not have to waive the copayment for the telehealth specialist 
visit provided on December 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction and primary closure of a sinus perforation 
(D7210, D7261) provided on December 12, 2022, by an opt-out provider, 
 
You asked the Plan to pay 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 the dental services were received from an out-of-
network provider who does not participate with Medicare 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 an extraction and primary closure of a sinus perforation (D7210, D7261) provided on December 12, 
2022, by an opt-out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation, periodontal 
maintenance, and intraoral x-rays (D4910, D0210, D0150) provided on October 25, 2022. 
 
You asked the Plan to pay more 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 $3000 dental benefit maximum 
allowance 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 October 25, 2022. 
Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation, periodontal 
maintenance, and intraoral x-rays (D4910, D0210, D0150) provided on October 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scans of the thorax and abdomen 
and pelvis provided on April 26, 2022.  
 
You asked the Plan to waive the copayment for the CT scans of the thorax and abdomen and pelvis. You say 
that you cannot afford to pay the copayments for the CT scans. 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 $300 
copayment for each Medicare-covered service. Prior authorization is required for some services by your doctor 
or other network provider. 
 You have been asked to pay a total of $300, which is less than the standard $600 for the CT scans of the thorax 
and abdomen and pelvis.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
April 26, 2022 CT scan, thorax $126.94 $300 $126.94 
April 26, 2022 CT scan, abdomen 
and pelvis 
$330.56 $300 $173.06 
TOTAL:    $300 
 
This CT scans fall within the outpatient diagnostic tests and therapeutic services and supplies 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 the CT scans of the thorax and abdomen and pelvis provided 
on April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the piflufolastat injection provided on 
November 18, 2022. 
 
You asked the Plan to waive the coinsurance for the piflufolastat injection. You say that you were not told what 
the coinsurance was. 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 outpatient diagnostic tests and therapeutic services and supplies.  
You have been asked to pay 20% coinsurance for the piflufolastat injection. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies 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. The total you owe is $1,080.25 ($5,401.26 allowed 
amount x 20% = $1,050.25). Therefore, we decided that the Plan does not have to waive the coinsurance for the 
piflufolastat injection provided on November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0364) provided on April 3, 2023. 
 
You asked the Plan to pay for the dental service. You say that the x-ray was needed to determine if you need a 
root canal. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the cone beam 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 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam (D0364) provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine transportation provided on February 3, 2023. 
 
You asked the Plan to pay for the routine transportation. You say that you are requesting reconsideration for the 
denial of reimbursement in the amount of $111.00 for transportation provided to the enrollees home from the 
urologist appointment. The Plan denied your request. The Plan says this is not a covered benefit under your 
plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when 42.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan for reimbursement for 
the expense for transportation home from the enrollees urologist appointment. Based on this information, we 
decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided 
that the Plan does not have to pay for routine transportation provided on February 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 2 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre Kit 2 sensor. You say that the enrollee's glucose has 
been fluctuating and will need to stabilize. You also say that the best way to monitor the glucose levels is by 
using the FreeStyle libre sensors. The Plan denied your request. The Plan says a continuous glucose monitor is 
covered under Medicare only if an enrollee with diabetes is on insulin or has documentation of history of 
problematic low blood sugars. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 FreeStyle Libre Kit 2 sensor. Our 
reviewer says that the FreeStyle Libre Kit 2 sensor is not medically necessary. Our physician reviewer found 
CGM coverage require either insulin use or low blood glucose sugar. The enrollee does not meet criteria 
coverage. Although the CGM would likely help control blood glucose sugar by seeing the impact of foods on 
the blood glucose sugar, coverage criteria are not met and we are not told why the finger stick would suffice. 
 
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 FreeStyle Libre Kit 2 sensor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a FreeStyle Libre Kit 2 sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound care supplies to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve wound care supplies. You say that your parent does not have a lot of 
provider options near her. The Plan denied your request. The Plan says there are other facilities in-network, that 
are in an allowable distance from the beneficiaries' residence. 
 
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 
wound care supplies 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 pre-approve placement of an intra-socket biological dressing to aid 
in hemostasis or clot stabilization, per site (D7922 x 7). 
 
You asked the Plan to pre-approve these dental services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says the requested services are 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 requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve placement 
of an intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922 x 7).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasties in conjunction with extractions-four or 
more teeth or tooth spaces, per quadrant (D7310 x 2). 
 
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 the requested services are 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 requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
alveoloplasties in conjunction with extractions-four or more teeth or tooth spaces, per quadrant (D7310 x 2).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on March 22, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the computed tomography scan provided 
on January 29, 2022. 
 
You asked the Plan to reduce the copayment for the computed tomography scan. You say that the plan denied 
services because the provider was out-of-network. 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 $225 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $225 copayment for the computed tomography scan. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies 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. However, since the allowed amount is 
less than the standard copayment, you only owe $207.29. Therefore, we decided that the Plan does not have to 
reduce the copayment for the computed tomography scan provided on January 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 15, 2022. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 an office visit provided 
on December 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the x-ray provided on January 24, 2023. 
 
You asked the Plan to waive the coinsurance for the x-ray. You say that you made a copayment at the time of 
visit. 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 in-network outpatient diagnostic tests provided at an outpatient hospital. 
 
You have been asked to pay 20% coinsurance for the x-ray. This item/service falls within the in-network 
outpatient diagnostic tests provided at an outpatient hospital 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. The total you owe is $16.62 ($83.08 allowed amount x 20% coinsurance = $16.62). Therefore, we decided that the Plan does not have to waive the 
coinsurance for the x-ray provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 06, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 an office visit provided 
on January 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) for tooth #20. 
 
You asked the Plan to pre-approve the dental service. You say that the core buildup is necessary to have the 
crown placed and you do not want to lose your tooth. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because 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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
core buildup (D2950) for tooth #20.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 23, 2023, by an out-of-
network (OON) provider.  
 
 You asked the Plan to pay for an office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 an office visit provided on February 23, 2023, by 
an out-of-network (OON) provider.