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

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve Freestyle Lite test strips. You say that you would like the Plan to approve 
these diabetic supplies. The Plan denied your request. The Plan says only the preferred brand products listed in 
the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Freestyle Lite test strips. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite 
test strips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the second opinion referral to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the referral. You say that you would like to see this provider. The Plan 
denied your request. The Plan says you must receive your care from a network provider. 
 
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 item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
second opinion referral 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 a prefabricated abutment placement (D6056), and an 
abutment supported crown (D6058). 
 
You asked the Plan to pre-approve dental implants. You say that you believe this should be covered. The Plan 
denied your request. The Plan says the denied dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated abutment placement (D6056), and an abutment supported crown (D6058).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 72 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips for follow-up 
appointments for surgery. You also say that these appointments are very important to avoid any medical 
complications from your surgery. The Plan denied your request. The Plan says your benefit only allows 
seventy-two (72) trips for this service.   
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 a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional trips for your follow-up appointments. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve 72 additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), and maxillary partial denture - cast metal framework with resin denture bases 
(including retentive/clasping materials, rests and teeth) (D5213). 
 
You asked the Plan to pre-approve the extractions, erupted tooth and maxillary partial denture. You say that no 
one told you that the plan will pay nothing for out-of-network dentists. The Plan denied your request. The Plan 
says these services are not covered expense 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 pre-approve the 
extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and maxillary partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on July 
19, 2023, to July 21, 2023. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not think you 
should be responsible for the 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 a $295 
copayment for each medically necessary inpatient stay. 
 
You have been asked to pay a $295 copayment for an inpatient hospital stay. This item/service falls within the 
each medically necessary inpatient stay 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 an inpatient hospital stay provided on July 19, 2023, to July 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor and reader. 
 
You asked the Plan to pre-approve the FreeStyle Libre 2 sensor and reader. You say that you have been 
spending hours on the phone trying to get your prescription filled. You also say that you need the sensor and 
reader to manage your diabetes. The Plan denied your request. The Plan says based on a review of the 
additional information received, you do not meet criteria for coverage of a Freestyle Libre 2 sensor and reader. 
Per the Medicare Guidelines, CGMs, you must be actively on insulin (at least once a day) or have a 
documented history of hypoglycemia. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of the FreeStyle Libre 2 sensor and reader have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a FreeStyle Libre 2 sensor and reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 28, 2023. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you were in the hospital when 
services were rendered. 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 $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for a specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 specialist visit provided on June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided on March 16, 
2023, to April 06, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically 
necessary. 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 pneumatic 
compression device provided on March 16, 2023, to April 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the outpatient surgery services on May 12, 
2023. 
 
You asked the Plan to waive the cost share for the outpatient surgery services. You say that there is 
miscommunications on the benefits received. 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 $150 
copayment for surgery services at an ambulatory surgical center. You must pay a 50% coinsurance for surgery 
services at an outpatient hospital and an ambulatory surgical center. The provider billed in the amount of 
$16,415.36 and the allowed amount is $416.89. For the service it's, $416.89 x 50% = $208.45. The Plan 
removed an extra penny. For both services it's, $150 + $208.44 = $358.44. Therefore, results in the total cost 
sharing amount of $358.44. 
 
You have been asked to pay a $150 copayment and a 50% coinsurance for the outpatient surgery services. This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
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. Therefore, we decided that the Plan does not have to waive the cost share for the 
outpatient surgery services on May 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the treatment of root canal obstruction (D3331). 
 
You asked the Plan to pre-approve D3331. You say that you need this in order to move forward with a root 
canal. The Plan denied your request. The Plan says the request dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
treatment of root canal obstruction (D3331).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 28, 2023. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided 
on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endosteal implants (D6010). 
 
You asked the Plan to pay for D6010. You say that you would like this to be covered. The Plan denied your 
request. The Plan says the rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for endosteal 
implants (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on June 21, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 a home visit evaluation 
provided on June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the enrollee had a libre pro flash ordered in January 
of 2021 and it is an outdated system you are trying to upgrade to a newer version. You also say that the enrollee 
has been having uncontrolled blood sugar levels and this is why they need it updated. The Plan denied your 
request. The Plan says there is no documentation that that the enrollee has lost the CGM or it has suffered 
irreparable damage. 
 
The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a 
capped rental item may be replaced in cases of loss or irreparable damage. 
 
We looked at the file and Medicare rules. The record does not show that the enrollees current CGM has 
sustained a loss or irreparable damage and is less than 5 years old so it is still within its reasonable useful 
lifetime. Based on this information, we decided that Medicare rules for coverage of the CGM have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental examination and treatment with an out-of-
network dental provider. 
 
You asked the Plan to pre-approve the dental services. You say that you need extensive dental work. You also 
say that you are unable to travel distances to the providers that are in-network. The Plan denied your request. 
The Plan says dental services from an out-of-network provider 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. 
 
 
  You are requesting 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 pre-approve dental 
examination and treatment with an out-of-network dental provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each ostomy supply provided on March 
31, 2023, to May 31, 2023. 
 
You asked the Plan to waive the coinsurance for each ostomy supply. You say that you disagree with the 
coinsurance. 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 durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for each ostomy supply. This item/service falls within the 
durable medical equipment and related 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 
coinsurance for each ostomy supply provided on March 31, 2023, to May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (D6011). 
 
You asked the Plan to pre-approve surgical access to an implant body (D6011). You say that you do not have 
the resources to pay for the termination of this procedure. You also say you are requesting that the termination 
of the dental implants be approved. The Plan denied your request. The Plan says these services are not covered 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical access to an implant body (D6011).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. You say that you do qualify for this benefit. The Plan 
denied your request. The Plan says the criteria for eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5284) and a 
mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the previous denture was terrible from the 
beginning. You also say that you were lacerating your gums, and there was bleeding and discomfort all the 
time. 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 April 15, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a removable unilateral partial denture 
(D5284) and a mandibular partial denture (D5214).