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

 
We decided that the Plan does not have to pay for infrared therapy devices provided on May 18, 2023. 
 You asked the Plan to pay for infrared therapy devices. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says infrared therapy devices are considered not 
reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the use of infrared therapy devices and any related 
accessories is not reasonable and necessary. The rules say that items and services that are not medically 
necessary are not covered. 
 
The services/items at issue in this appeal are for infrared therapy. Therefore, we decided that the Plan does not 
have to pay for infrared therapy devices provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for eyeglasses purchased from an out-of-network provider 
on August 30, 2023. 
 
You asked the Plan to reimburse for eyeglasses purchased from an out-of-network provider. You say that you 
called the Plan and were told that this provider was in-network. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services, however, there is a 40% coinsurance for Medicare-covered eyeglasses 
when obtained out-of-network. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a 40% coinsurance for out-of-network 
Medicare-covered eyeglasses or contact lenses after cataract surgery. Based on this information, we decided 
that the Plan's rules for coverage of eyeglasses purchased from an out-of-network provider have not been met. 
Therefore, we decided that the Plan does not have to reimburse for eyeglasses purchased from an out-of-
network provider on August 30, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the mandibular partial denture adjustment (D5422) provided on 
September 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were informed this procedure was approved 
for coverage and you do not have the money to pay this bill. The Plan denied your request. The Plan says that 
your benefit for the requested item or service has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Additionally, there is no benefit citation in the EOC or dental rider limiting the adjustments to being 
six months apart. The only limitation is the adjustments cannot be done until six months after the initial 
placement. Therefore, we decided that the Plan has to pay for the mandibular partial denture adjustment 
(D5422) provided on September 6, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standard lens, polycarbonate or equal, any index, per 
lens, frame, and bifocal lens purchased on September 8, 2023, from a non-participating provider. 
 
You asked the Plan to pay for the eyewear. You say that the staff member at the rendering provider's office 
called the Plan and was advised that you would be covered. You also say that you only paid $20, and they did 
not ask you to pay for anything else because they said the Plan would take care of this. The Plan denied your 
request. The Plan says this claim is from a provider who is not in the Plan's network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is purchased from a Plan approved vision provider. 
 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record show that the eyewear you received was 
purchased from an out-of-network provider. Based on this information, we decided that the Plan's rules for 
coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the 
standard lens, polycarbonate or equal, any index, per lens, frame, and bifocal lens purchased on September 8, 
2023, from a non-participating provider.  
 
Your complaint about being misinformed by the staff member at the provider's office is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on September 
11, 2023. 
 
You asked the Plan to pay for evaluation and management services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says they have made several calls 
to the primary care provider to request the claim information, but they advised that they will be billing the 
claim to the primary insurance.  
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has an 
explanation of benefits (EOB) from the enrollee's primary insurance carrier is needed before this claim can be 
considered. As the secondary insurer, the Plan cannot be held responsible for evaluation and management 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for evaluation and management services provided on September 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) for all 4 quadrants provided 
on April 13, 2023. 
  You asked the Plan to pay for the dental services. You say that you have called several times to get the billing 
issue resolved. The Plan denied your request. The Plan says the denial of payment for these services is correct 
because the gingival irrigation is not covered by the Plan. Also, it was verified that there were no calls made to 
the Plan prior to the date of 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation (D4921) for all 4 quadrants provided on April 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the denosumab injection and the IV therapy 
provided on July 27, 2023. 
 
You asked the Plan to waive the cost share for the injection and IV therapy. You say that you disagree with the 
cost share applied to this claim. 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 all other in-network Medicare Part B prescription drugs. The Plan contract also says that 
enrollees must pay a $150 copayment for in-network outpatient hospital services. 
 
You have been asked to pay $297.09, which is 20% coinsurance of the allowed amount for the injection 
($1,485.43 allowed amount x 20% coinsurance = $297.09). This item/service falls within the Medicare Part B 
prescription drugs benefit category.  
 
You have also been asked to pay $64.08, which is less than the standard copayment for the IV therapy. This 
service falls within the outpatient hospital services benefit category. You have been asked to pay a total of 
$361.17 ($64.08 copayment + $297.09 coinsurance = $361.17). 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 denosumab injection and the IV therapy provided on July 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crutch substitute provided on January 18, 2023. 
 
You asked the Plan to pay for the crutch substitute. You say that you would like reimbursement for the 
equipment. The Plan denied your request. The Plan says rendering provider is a non-Medicare participating 
supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the crutch substitute provided on January 
18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for open procedures involving hip joint; total hip 
arthroplasty, ultrasonic guidance for needle placement provided on March 28, 2023. 
 
You asked the Plan to pay for anesthesia for open procedures involving hip joint; total hip arthroplasty, 
ultrasonic guidance for needle placement. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the plan did not receive a primary carriers Explanation of Benefits (EOB). 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has called 
provider to submit the primary an EOB. As the secondary insurer, the Plan cannot be held responsible for 
anesthesia for open procedures involving hip joint; total hip arthroplasty, ultrasonic guidance for needle 
placement until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for anesthesia for open procedures involving hip joint; total hip arthroplasty, ultrasonic 
guidance for needle placement provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on June 15, 
2023, to July 08, 2023. 
 
You asked the Plan to pay for evaluation and management services. You say that you are requesting 
reconsideration for 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 evaluation and 
management services provided on June 15, 2023, to July 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on October 10, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they cover only manual manipulation of the spine to 
correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided on October 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on May 11, 2023, to May 17, 
2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they cover only manual manipulation of the spine to 
correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic services provided on May 11, 2023, to May 17, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 03, 2023, to July 26, 
2023. 
 
You asked the Plan to pay for psychotherapy. You say that the EOC says no referral needed for providers that 
are not psychiatrists. 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 January 03, 2023, to July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for extraction of tooth# 26 (D7140) provided 
on August 25, 2023. 
 
You asked the Plan to waive the coinsurance for extraction of tooth# 26 (D7140). You say that this should be 
covered in full. 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 class 2 basic dental services. 
 
You have been asked to pay 20% coinsurance for extraction of tooth# 26 (D7140). This item/service falls 
within the class 2 basic 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 extraction of tooth# 26 (D7140) provided on August 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 25, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for 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 an office visit provided 
on July 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 24, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that these supplies are a separately billable 
expense that do not require authorization. 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 wound care supplies 
provided on August 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on June 30, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. 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 proof of delivery. Specifically, there is no signed receipt of the delivery. 
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 pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on June 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the skin lesion excision provided on 
August 14, 2023, and the complex repair procedure provided on August 15, 2023. 
 
You have asked the Plan to reduce the copayment for the skin excision and repair procedure. You have had 
multiple procedures like this in the past and should only be responsible for a $35 specialist 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 $330 
copayment per visit outpatient surgeries.  
 
You have been asked to pay a $330 copayment for the skin lesion excision provided on August 14, 2023. You 
have also been asked to pay a $330 copayment for the complex repair procedure provided on August 15, 2023. These services fall within the outpatient 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 copayment 
for the skin lesion excision provided on August 14, 2023, and the complex repair procedure provided on 
August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lens, the tint and the anti-reflective coating provided on 
October 2, 2023. 
 
You asked the Plan to pay for the lens, the tint and the anti-reflective coating. You say that the only thing you 
have to pay for is the tint. You say everything else is automatically added in the price of the glasses. The Plan 
denied your request. The Plan says the services are not covered. 
 
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 standard frames and lenses. 
 
We looked at the file and the Plan's rules. Specifically, upgrades are not covered benefits. Based on this 
information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the lens, the tint and the anti-reflective coating provided on October 2, 2023.