Persius/hicric huggingface dataset:
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 March 7, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that 911 was 
called and you were checked by the ambulance paramedics. You also say that the paramedics suggested your 
husband drive you to the emergency room. 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 March 7, 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 March 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomographic angiography 
(CTA) scan provided on March 23, 2023. 
 
You asked the Plan to waive the copayment for a computed tomographic angiography (CTA) scan. You say 
that the CTA was required to be completed prior to having another procedure. 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 $175 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $175 copayment for a computed tomographic angiography (CTA) 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 copayment for a computed tomographic angiography (CTA) scan provided on March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 14 day sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 14 day sensor. The Plan denied your request. The Plan 
says the enrollee is not receiving insulin and has not had documented hypoglycemic episodes. 
 
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 the enrollee does 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 14 day sensor  have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the FreeStyle Libre 14 day sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
November 2, 2022. 
 
You asked the Plan to pay for the dental service. You say that the provider never told you that you exceeded 
your benefit limit. 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 the Plan paid for a comprehensive oral evaluation (D0150) on March 9, 2022; therefore, your benefit for 
the requested item or service was exhausted on the date of service of March 9, 2022. Therefore, we decided 
that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on November 2, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on May 12, 2023. 
 You asked the Plan to pay for the anesthesia. You say that the records provided support medical necessity. 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 anesthesia services provided on May 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation (D0140), the core buildup 
(D2950), the guided tissue regeneration (D4266), and the retainer crown (D6740) for tooth #27, #28, and #29 
provided on January 10, 2023. 
 You asked the Plan to pay more for the dental services. You say that you were told that you needed a bridge 
and you did not know that it would cost $9,000. The Plan denied your request. The Plan says your annual 
dental maximum benefit for the year 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 the Plan paid $2,861 for dental services on January 10, 2023. On February 7, 2023, which was processed 
prior to the claim for January 10, 2023, the Plan paid $139 for dental services. For the year of 2023 the Plan 
paid $3,000 ($2,861 paid + $139 paid) for dental services; therefore, your annual dental maximum benefit for 
the year of 2023 was exhausted on the date of service of February 7, 2023. Therefore, we decided that the Plan 
does not have to pay more for the limited oral evaluation (D0140), the core buildup (D2950), the guided tissue 
regeneration (D4266), and the retainer crown (D6740) for tooth #27, #28, and #29 provided on January 10, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on April 28, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were not 
expecting this high copayment because you thought the CT scan would be rolled into the surgery. 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 $350 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $350 copayment for a computed tomography (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 copayment for a 
computed tomography (CT) scan provided on April 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation with a medical health care professional (D9311) 
provided on March 15, 2023. 
 
You asked the Plan to pay for consultation with a medical health care professional. 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 
consultation with a medical health care professional (D9311) provided on March 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on May 13, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were not 
advised of a cost share. 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 $250 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $250 copayment for a computed tomography (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. The total you owe is $148.64, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on May 13, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen. 
 
You asked the Plan to pre-approve the CT scan of the abdomen. You say that the services are medically 
necessary. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
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 abdomen. Our 
reviewer says that the CT scan is medically necessary. Our physician reviewer found the enrollee has 
hyponatremia and the prior CT of the abdomen done on January 5, 2023, showed a 1.9 centimeter left adrenal 
mass or nodule thought to reflect an adrenal adenoma.  In an enrollee with hyponatremia and an adrenal mass it 
is important to exclude any growth in the left adrenal nodule since adrenal neoplasm may present in a similar 
way.  Request for CT scan of the abdomen should be approved. 
 
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 abdomen have been met. Therefore, we decided that the Plan 
has to pre-approve a computed tomography (CT) scan of the abdomen.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan 
provided on March 17, 2023. 
 
You asked the Plan to reduce the copayment for a computed tomography (CT) scan. You say that you were 
advised the cost share would only be $45 which you paid at the time of service. 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 outpatient diagnostic tests. 
 
You have been asked to pay a $150 copayment for a computed tomography (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 reduce the copayment for a 
computed tomography (CT) scan provided on March 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 21, 2023. 
 
You asked the Plan to pay for dental services. You say that this was medically necessary. The Plan denied your 
request. The Plan says you do not have dental benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on 
February 21, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility visits provided on March 16, 2023. 
 
You asked the Plan to pay for skilled nursing facility visits. You say that the records attached support the 
services provided. 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 skilled nursing facility 
visits provided on March 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each physical therapy (PT) visit provided 
on March 08, 2023, to April 05, 2023. 
 
You asked the Plan to reduce the copayment for each physical therapy (PT) visit. You say that you only paid a 
$10 copayment for each PT vist last year and you feel that you should not have to pay a $40 copayment for the 
same service this 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 $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. The total copayment you owe is $160 for PT visits ($40 per visit x 4 visits = 
$160). Therefore, we decided that the Plan does not have to reduce the copayment for each physical therapy 
(PT) visit provided on March 08, 2023, to April 05, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued skilled nursing facility stay provided from 
February 2, 2023, to March 3, 2023. 
 
You asked the Plan to pay for continued skilled nursing facility stay. You say that the services received should 
be covered under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 100-day SNF 
benefit is exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from March 31, 2022, 
to March 3, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the continued skilled nursing facility stay provided from February 2, 
2023, to March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each therapeutic radiology visit provided 
on September 01, 2022, to September 21, 2022. 
 
You asked the Plan to waive the copayment for each therapeutic radiology visit. You say that you are on a 
limited income and unable to afford the copayment applied. 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 $60 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $60 copayment for each therapeutic radiology visit. 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. The total copayment you owe is $840 for radiology therapy ($60 per visit x 14 
visits). Therefore, we decided that the Plan does not have to waive the copayment for each therapeutic 
radiology visit provided on September 01, 2022, to September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) and endodontic therapy 
(D3320) provided on November 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did see an in-network dentist. 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 limited oral evaluation (D0140) and endodontic therapy (D3320) provided on November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gym membership provided on January 1, 2022. 
 
You asked the Plan to pay for gym membership. You say that because you also got denied for reimbursement 
for last years coverage. The Plan denied your request. The Plan says this benefit has already been paid. 
 
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 $250 per 
calendar year towards your cost for membership in a qualified health club or fitness facility during the calendar 
year. 
 
  The Plans rules for coverage of gym benefits have not been met because The Plan rules say that the benefit 
includes a plan reimbursement of up to $250 per calendar year towards your cost for membership in a qualified 
health club or fitness facility during the calendar year, covered instructional fitness classes. The record shows 
that this benefit has already been exhausted. Therefore, we decided that the Plan does not have to pay for a gym 
membership provided on January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service August 3, 2021. Specifically, the 
Plans contract states that complete dentures are covered once every five years.  
  
 
 
 
You previously received a complete upper denture on August 3, 2021, less than five years prior, which was 
paid for by the Plan. Therefore, you have exhausted the allowable benefit for the dental item requested in this 
case. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) 
provided on June 9, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
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 the extraspinal chiropractic manipulative treatment (98943) provided on  
June 9, 2023.