Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown - porcelain/ceramic tooth #11 (D6740), and 
pontic - porcelain/ceramic tooth #10 (D6245) provided on January 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have never been in-active with the plan. 
You also say that you made a change to coverage last year. The Plan denied your request. The Plan says your 
benefit for the requested services has already been exhausted. After analyzing the facts pertaining to your case,  
4 fixed bridge units were covered under the 2023 EOC and have already been paid for. 
 
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 retainer crown - porcelain/ceramic tooth #11 (D6740), and pontic - 
porcelain/ceramic tooth #10 (D6245) was exhausted on date of service January 17, 2023. Therefore, we 
decided that the Plan does not have to pay for a retainer crown - porcelain/ceramic tooth #11 (D6740), and 
pontic - porcelain/ceramic tooth #10 (D6245) provided on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care provided on January 31, 2023. 
 You asked the Plan to pay for initial hospital care. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for initial hospital care provided on January 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor.  
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
coverage criteria have not been met. 
 
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 provided does not indicate that the enrollee uses 
insulin or have a history of problematic hypoglycemia. Based on this information, we decided that Medicare 
rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) radiofrequency ablation (RFA) 
under conscious sedation. 
 You asked the Plan to pre-approve a SIJ RFA. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that  
 
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 a SIJ RFA. Our reviewer says that the 
documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has sacral spondylosis and sacral joint pain. The enrollee had excellent 
pain relief and functional improvement from sacral lateral branch blocks. According to the literature, sacral 
lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint 
mediated pain is considered experimental and investigational. Studies completed say that this procedure does 
not improve outcomes compared to standard treatment of SIJ pain. Radiofrequency ablation for denervation, 
whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and 
therefore, not medically necessary. Therefore, the enrollee does not meet criteria for the requested services. 
 
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 SIJ RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac joint (SIJ) radiofrequency ablation (RFA) under conscious sedation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) provided on September 27, 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 annual $2,500 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 September 27, 2022. 
Therefore, we decided that the Plan does not have to pay more for a crown (D2740) provided on September 27, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an esophagus x-ray, and hearing services provided on 
January 27, 2023. 
 
You asked the Plan to pay for an esophagus x-ray, and hearing services. You say that these are tests for 
approved medical procedures. 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 esophagus x-ray, and 
hearing services provided on January 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips (A0100). 
 You asked the Plan to pre-approve the additional non-emergency transportation trips. You say that you need 
the additional trips for future doctor's office visits. The Plan denied your request. The Plan says services are 
limited to 24 one-way trips per calendar year. The Plan also says that you have had only 8 one-way trips out of 
the 24 trips allowed. 
 
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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 additional non-emergency transportation trips (A0100).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric sit to stand lift. 
 
You asked the Plan to pre-approve an electric lift. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says that this item/service is not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-
approve an electric sit to stand lift.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetes outpatient self-management training services 
provided on October 3, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the diabetes outpatient self-management training services. You say that the 
services billed are supported in the records. The Plan denied your request. The Plan says enrollees must receive 
their 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 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 
items/services 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 diabetes outpatient self-management training 
services provided on October 3, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the cervical spine 
provided on October 18, 2022. 
 
You asked the Plan to pay for the CT scan. You say that you have submitted the waiver of liability (WOL) and 
the claim should be reprocessed. The Plan denied your request. The Plan says Original Medicare is responsible 
for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a computed tomography (CT) scan of the cervical spine 
provided on October 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for Privigen injection provided on January 
18, 2023. 
 
You asked the Plan to reduce the coinsurance for Privigen injection. You say that you can not afford to pay the 
coinsurance for the injection. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Privigen injection. This item/service falls within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance for 
Privigen injection provided on January 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cxbladder test provided on November 29, 2022. 
 
You asked the Plan to pay for a cxbladder test. You say that this service 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 cxbladder test 
provided on November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-ray, 2D 
oral/facial photographic image, the application of fluoride varnish, and a cleaning (D1206, D1110, D0350, 
D0210, D0150) provided on December 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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 a comprehensive oral evaluation, intraoral x-ray, 2D oral/facial photographic image, the application 
of fluoride varnish, and a cleaning (D1206, D1110, D0350, D0210, D0150) provided on December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on March 7, 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 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 for a cleaning (D1110) provided on March 7, 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 November 12, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
you should not be responsible for the $250 copayment being that you were never transported. 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 November 12, 2022. 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 November 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom sleep apnea appliance fabrication and placement 
(D9947/99199) provided on October 12, 2022. 
 
You asked the Plan to pay for a custom sleep apnea appliance fabrication and placement. You say that you 
needed this device. The Plan denied your request. The Plan says these 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 a custom 
sleep apnea appliance fabrication and placement (D9947/99199) provided on October 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a CT scan provided on February 18, 2023. 
 
You asked the Plan to waive the cost share for a CT scan. You say that you are disappointed the Plan denied 
coverage for an important medical test. 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 $200 
copayment for each Medicare-covered CT scan.  You have been asked to pay a total cost share of $99.73 for a CT scan. The total includes a $13.24 deductible, 
because it was not met at the time of service, and $86.49, which is less than the standard $200 copayment for a 
CT scan. This item/service falls within the outpatient diagnostic tests 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 a CT scan provided on February 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3. 
 
You asked the Plan to pre-approve a Freestyle Libre 3. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says that the requested Freestyle Libre 3 is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on January 
26, 2023, to February 08, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were transferred from 
one facility to another so you should not be charged for the inpatient 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 you must pay a $200 
copayment for inpatient hospital care. 
 
You have been asked to pay a $200 copayment for inpatient hospital stay. This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The total you owe is $1,200 ($200 copayment x 6/days = $1,200). Therefore, we decided 
that the Plan does not have to waive the copayment for inpatient hospital stay provided on January 26, 2023, to 
February 08, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on February 4, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says that self-administered drugs do not fall under Medicare Part B coverage. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on February 4, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) and 2D oral/facial 
photographic image (D0350) provided on January 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that these procedures were necessary. The Plan 
denied your request. The Plan says these services are not covered under the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral 
hygiene instructions (D1330) and 2D oral/facial photographic image (D0350) provided on January 18, 2023.