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

 
We decided that the Plan does not have to waive the copayment for an in-network office visit provided on 
August 09, 2023. 
 
You asked the Plan to waive the copayment for an in-network office visit. You say that you feel you should not 
have to pay this 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for an in-network office visit. This item/service falls within the physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. However, since the allowed amount is less than the 
standard copayment, you only owe $22.48. Therefore, we decided that the Plan does not have to waive the 
copayment for an in-network office visit provided on August 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), intraoral-
comprehensive series of radiographic images (D0210), dental cleaning (D1110), and the adjunctive pre-
diagnostic test (D0431) provided on August 2, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Additionally, an adjunctive pre-diagnostic test and an intraoral-comprehensive series of radiographic 
images are not covered under the supplemental dental policy.  
  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, an adjunctive pre-diagnostic test and an intraoral-comprehensive series of radiographic images 
are not covered under the supplemental dental policy. Therefore, we decided that the Plan does not have to pay 
more for the comprehensive oral evaluation (D0150), intraoral-comprehensive series of radiographic images 
(D0210), dental cleaning (D1110), and the adjunctive pre-diagnostic test (D0431) provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the incisional biopsy of oral tissue (D7286) 
and the pathology services provided on June 30, 2023. 
  
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the incisional 
biopsy of oral tissue is not a covered benefit under the supplemental dental policy. Additionally, the pathology 
services provided are not covered as they were rendered by an out-of-network provider, without prior 
authorization.  
 
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. 
 
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 incisional biopsy of oral tissue is 
not among those covered under this benefit. Additionally, the pathology services provided in this case are not  
covered as they were rendered by an out-of-network provider, without prior authorization. Therefore, we 
decided that the Plan does not have to issue reimbursement for the incisional biopsy of oral tissue (D7286) and 
the pathology services provided on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781), lenses (V2782), anti-reflective 
coating (V2750), and deluxe frames (V2025) provided on August 30, 2023. 
 
You asked the Plan to pay for progressive lenses (V2781), lenses (V2782), anti-reflective coating (V2750), and 
deluxe frames (V2025). You say that the glasses are blurry, and you cannot see well out of them. You also say 
the provider would not issue you a refund. The Plan denied your request. The Plan says there is a $175 plan 
coverage limit for routine eyewear (in- and out-of-network). The Plan also says that you must pay the 
difference between the plan's benefit and the cost of the eyewear. The Plan also says that you are limited to one 
pair of eyeglasses (lenses and frames) or contact lenses (conventional or disposable) per year, not to exceed the 
annual allowance. 
 
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 . 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $175 Plan coverage limit for routine 
eyewear. The Plan rules also say that you must pay the difference between the plans benefit and the cost of the 
eyewear. The record shows you were seen and purchased eyewear on this date of service. The record also 
shows this benefit was exhausted on August 30, 2023. Based on this information, we decided that the Plan's 
rules for coverage of progressive lenses (V2781), lenses (V2782), anti-reflective coating (V2750), and deluxe 
frames (V2025) have not been met. Therefore, we decided that the Plan does not have to pay for progressive 
lenses (V2781), lenses (V2782), anti-reflective coating (V2750), and deluxe frames (V2025) provided on 
August 30, 2023.  
 
Your complaint about the potentially poor customer service 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on June 26, 2023. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 30, 2023. 
 
You asked the Plan to pay for the office visit. You say that you were referred to this chiropractor and the office 
visit was necessary. The Plan denied your request. The Plan says the service was 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 office visit provided on May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214), a determination of refractive state 
(92015), a special eye evaluation (92060), neurobehavioral status examination (96116) and a visual field 
examination (92081) provided from September 26, 2023, to September 27, 2023. 
 
  You asked the Plan to pay for an office visit (99214), a determination of refractive state (92015), a special eye 
evaluation (92060), neurobehavioral status examination (96116) and a visual field examination (92081). You 
say that you were unaware that the provider had opted out of Medicare. You also say that you had to take out a 
personal loan to pay the bills. The Plan denied your request. The Plan says this provider has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit (99214), a determination of refractive state (92015), a special eye evaluation (92060), neurobehavioral 
status examination (96116) and a visual field examination (92081) provided from September 26, 2023, to 
September 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the insulin infusion pump provided on 
June 30, 2023. 
 
You asked the Plan to waive the coinsurance for the insulin infusion pump. You say that you are on a very low 
income and cannot afford to pay $720. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for the insulin infusion pump. This item/service falls within the 
durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. The total you owe is $720 ($3,600 allowed amount x 20% = 
$720). Therefore, we decided that the Plan does not have to waive the coinsurance for the insulin infusion 
pump provided on June 30, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) care provided from March 25, 2023, to 
March 31, 2023. 
 
You asked the Plan to pay for SNF care. You say that your contracted rates are by revenue code/level per day, 
not the patient-drive payment model (PDPM) code which is for informational purposes only. The Plan denied 
your request. The Plan says that the billed code ODGC1 does not match what was approved on the 
authorization which was OGXD. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the authorization approved by the Plan does not include a valid 
PDPM code. Therefore, this authorization does not prevent the provider from reporting the PDPM code of 
ODGC1. The Plan has not shown that its denial is correct or justified based on Medicare billing rules. 
Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care provided from March 25, 
2023, to March 31, 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 eyewear provided on August 1, 2023. 
 
You asked the Plan to pay for the eyewear . You say that you have not purchased eyewear for several years and 
paid more than $600 for the glasses. The Plan denied your request. The Plan says the benefit has been 
exhausted. 
 
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 up to a $125 allowance every calendar year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $125 towards the eyewear, which 
exhausted the benefit. 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 eyewear provided on 
August 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that you have diabetes and informed your doctor that 
you refuse to continue the OneTouch or any other monitoring system that calls for you to stick yourself several 
times daily for the rest of your life. You also say that you are willing to try a constant monitoring system that 
will allow you to apply and read A1C levels throughout the following use of this device. The Plan denied your 
request. The Plan says you do not meet the Medicare criteria for coverage of a CGM as you are not insulin 
dependent and do not have a history of problematic hypoglycemia.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM. Our reviewer says that this 
item is not medically necessary. Our physician reviewer found coverage criteria for CGM require insulin use or 
low blood glucose sugar. You are not on medications that typically cause low blood glucose sugar and we are 
not told of low blood glucose sugar, nor of plans for insulin use. Although you would likely benefit from a 
CGM, coverage criteria are not met. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81162). 
 
You asked the Plan to pre-approve the genetic testing. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the requested test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for a genetic test to be covered it must have 
satisfactorily completed a Technical Assessment (TA) by Molecular Diagnostic Services Program (MolDX) for 
the stated indications of the test. 
 
We looked at the file and Medicare rules. The requested test is not listed as a covered test on the MolDX 
database. Based on this information, we decided that Medicare rules for coverage of the genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81162).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care provided on July 11, 2023. 
 You asked the Plan to pay for the hospital care. You say that the enrollee was not on hospice on this date. 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 hospital care provided on July 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this high intensity rehabilitation to 
regain mobility and independence and return home. The Plan denied your request. The Plan says the request for 
Inpatient Rehabilitation Facility services does not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and periodontal maintenance 
(D4910) provided on June 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware you needed prior 
authorization every time you visited an out-of-network provider. 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 the panoramic x-ray (D0330) and periodontal maintenance (D4910) provided on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays, cleaning, and amalgam (D0274, D1110, 
D2150) provided on June 26, 2023, to August 14, 2023, by an out-of-network (OON) provider. 
 
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 bitewing x-rays, cleaning, and amalgam (D0274, D1110, D2150) provided on June 26, 2023, to 
August 14, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and extraction (D7210, D0220) provided 
on August 3, 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 the services denied correctly as they do not fall 
within your 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 an 
intraoral x-ray and extraction (D7210, D0220) provided on August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye examination, deluxe frames, the bifocal lens, 
the tint, and the anti-reflective coating provided on January 27, 2023. 
 
You asked the Plan to pay for the medical eye examination, deluxe frames, the bifocal lens, the tint, and the 
anti-reflective coating. You say that you are appealing this denial. The Plan denied your request. The Plan says 
the provider was out-of-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 received in-network. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network, and the Plan does not 
have out-of-network benefits. Based on this information, we decided that the Plan's rules for coverage of the 
medical eye examination, deluxe frames, the bifocal lens, the tint, and the anti-reflective coating have not been 
met. Therefore, we decided that the Plan does not have to pay for the medical eye examination, deluxe frames, 
the bifocal lens, the tint, and the anti-reflective coating provided on January 27, 2023.