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

 
We decided that the Plan does not have to pre-approve a FreeStyle 3 Libre sensor. 
 
You asked the Plan to pre-approve the FreeStyle 3 Libre sensor. 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 3 Libre sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral- periapical each additional radiographic image 
(D0230 x7) provided on March 20, 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 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 March 20, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral- periapical each additional radiographic 
image (D0230 x7) provided on March 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 4, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would 
like for these services to be reconsidered. The Plan denied your request. The Plan says these services are not a 
covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 9, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on February 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thoracic spine 
and the lumbar spine.  
 
You asked the Plan to pre-approve the CT scan of the thoracic spine and the lumbar spine. You say that the 
services are medically necessary. The Plan denied your request. The Plan says you have not completed six 
weeks of provider directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
 
 
 
 
 
 
 
 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 CT scan of the thoracic spine and 
the lumbar spine. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found 
plain films showed degenerative changes and no compression fracture. The enrollee has tried physical therapy 
(PT) in the past but according to the records there was a flare up of symptoms with PT.  The utility of CT 
without intrathecal contrast in an enrollee with prior fusion is marginal. Without such contrast scar formation is 
very difficult to distinguish from disc disease.  Since this enrollee has had spinal surgery in the past it should be 
the decision of a spinal specialist what type of workup if any this enrollee needs.  Since a CT myelogram has 
some attendant risk due to lumbar puncture the decision should be made by a spinal specialist. 
 
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 CT scan of the thoracic spine and the lumbar spine have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
thoracic spine and the lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for dumbbells purchased on January 1, 2023. 
 
You asked the Plan to reimburse for dumbbells. You say that you have the wellness benefit reimbursement of 
$150. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only The Plan rules say that they will reimburses you up to $150 each calendar year your cost for membership 
in a qualified health club or fitness facility during the calendar, covered instructional fitness classes, 
participation in wellness programs, and/or covered nutritional counseling sessions with a licensed nutritional 
counselor or registered dietician. 
 
 
  The Plans rules for coverage of gym benefits have not been met because this is not a covered item under your 
wellness allowance benefit. Dumbbells are not covered under this benefit. Therefore, we decided that the Plan 
does not have to reimburse for dumbbells purchased on January 1, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for PET scan and medical supplies provided on 
February 1, 2023. 
 
You asked the Plan to waive the copayment for radiology services. You say that you should not have to pay the 
billed charges because you were not satisfied with the facility. 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 10% 
coinsurance for each Medicare-covered medical supply and $55 copayment for other Medicare-covered 
radiological diagnostic services, not including x-rays, performed in a physicians office or at a free-standing 
facility (such as a radiology center or medical clinic 
 
You have been asked to pay a total of $67.50 for radiology services.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
February 1, 2023 PET scan $1556.35 $55 $55 
February 1, 2023 medical-supplies $125 10% $12.50 
TOTAL:    $67.50 
 
These item/service fall within the surgical supplies, such as dressings and other outpatient diagnostic tests - 
Radiological diagnostic services, not including x-rays 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 PET scan and medical supplies provided on February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant, 
and semi-precision attachment abutment (D6010, D6052). 
 
You asked the Plan to pre-approve implants and associated services. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of implant body: endosteal implant, and semi-precision attachment abutment (D6010, 
D6052).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown-porcelain/ceramic provided on February 2, 2023. 
 
You asked the Plan to pay for a crown-porcelain/ceramic. You say that this should be covered. The Plan denied 
your request. The Plan says only stainless-steel crowns are covered. 
 
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 a crown-
porcelain/ceramic provided on February 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided February 1, 2023, to February 
17, 2023. 
 
You asked the Plan to pay for home health services. You say that these services were medically necessary. 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 February 1, 2023. The NOA was not received by the Plan until April 12, 
2023. 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 home health services provided 
February 1, 2023, to February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided March 13, 2023, by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that you were misquoted for these services. 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 dental services provided March 13, 2023, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft (D7953) provided on April 12, 2022. 
 
You asked the Plan to pay for bone replacement graft. 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 bone 
replacement graft (D7953) provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pulp cap - indirect (excluding final restoration) (D3120) 
provided on March 30, 2023. 
 
You asked the Plan to pay for the pulp cap - indirect. You say that the provider did not ask permission before 
performing the procedure. You also say that you feel you should not be liable for this service. The Plan denied 
your request. The Plans says D3120 is not listed as a covered benefit. The Plan also says for more detailed 
description of covered dental services, including frequency and code limitations that may apply, refer to the 
dental addendum available at the website address provide on page 61 of the EOC. 
 
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, pulp cap  indirect is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for a pulp cap - indirect 
(excluding final restoration) (D3120) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) and the ear molds 
(V5264) purchased on October 27, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items at issue are not payable 
as they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Additionally, hearing aid accessories are not a covered benefit.  
  
 
 
Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) and the 
ear molds (V5264) purchased on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral 
- periapical first radiographic image (D0220) and pulp vitality tests (D0460) provided on February 9, 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 limited oral evaluation and intraoral - periapical first radiographic 
image has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 21, 2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused 
(D0140), intraoral - periapical first radiographic image (D0220) and pulp vitality tests (D0460) provided on 
February 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for vision supply, accessory (V2797) and frames (V2020) 
provided on January 13, 2023. 
 
You asked the Plan to reimburse for vision supply, accessory (V2797) and frames (V2020). You say that you 
took your glasses in to be fixed, and they kept falling off your face. You also say you finally went back, but 
with an old frame and they would not put your new prescription in your old frame. The Plan denied your 
request. The Plan says although you were dissatisfied with the eyewear that was dispensed, it has been 
confirmed that the services were rendered. 
 
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 $200 for routine eyewear every year from a Plan vendor provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $200 coverage limit for routine 
eyewear every year from a Plan vendor provider. The record shows the services were rendered on January 13, 
2023. Therefore, this benefit has been exhausted. Based on this information, we decided that the Plan's rules for 
coverage of vision supply, accessory (V2797) and frames (V2020)  have not been met. Therefore, we decided 
that the Plan does not have to reimburse for vision supply, accessory (V2797) and frames (V2020) provided on 
January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete mandibular denture (D5120) provided on 
February 10, 2023. 
 
You asked the Plan to pay for D5120. You say that the Plan made the mistake, and this denture is medically 
necessary. The Plan denied your request. The Plan says the rendered 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 pay for a 
complete mandibular denture (D5120) provided on February 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on April 18, 2020, to April 18, 2023.  
 
You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because the requested 
foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on April 18, 
2020, to April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on February 07, 2023. 
 
You asked the Plan to pay for an office visit (99213). You say that at no time were you advised by the Plan that 
you could not continue to see other organizations for care. 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 (99213) 
provided on February 07, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
March 5, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you should not have to pay 
the billed charges for this stay. 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 that per admission, you 
pay a copayment of $325 per day for days 1-5. 
  You have been asked to pay a total of $325 for the 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 the inpatient 
hospital stay provided on March 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for periodontal maintenance (D4910), topical 
application of fluoride varnish (D1206), periodic oral evaluation - established patient (D0120) provided on 
April 4, 2023. 
 
You asked the Plan to waive the coinsurance for the periodontal maintenance, topical application of fluoride 
varnish and periodic oral evaluation. You say that should not be responsible for this amount due. You also say 
that you were not made aware of the changes made from the plan from the 2022-2023 plan year. 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% 
coinsurance when not seen by a plan provider, you pay 50% of the total allowed amount out-of-network for 
preventive and comprehensive dental services.  
 
You have been asked to pay a 50% coinsurance for the periodontal maintenance, topical application of fluoride 
varnish and periodic oral evaluation. These service falls within the dental services benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for periodontal maintenance (D4910), topical application of fluoride 
varnish (D1206), periodic oral evaluation - established patient (D0120) provided on April 4, 2023.