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

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) x2. 
 
You asked the Plan to pre-approve the dental services. You say that you need the current crowns replaced. The 
Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve crown - 
porcelain/ceramic (D2740) x2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal 
maintenance (D4910).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan of extracranial arteries 
provided on March 20, 2023. 
 
You asked the Plan to waive the copayment for a duplex scan of extracranial arteries. You say that you thought 
that you were supposed to have a $0 copayment for this 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 $50 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service. 
 
You have been asked to pay a $50 copayment for a duplex scan of extracranial arteries. This item/service falls within the diagnostic procedures and tests, including ultrasounds, at all locations of service 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 duplex scan of extracranial arteries provided on March 20, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. 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 items 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 items was exhausted on date of service December 8, 2020.  
  
 
 
 
Specifically, the Plans contract states that partial dentures are covered (1 per arch) every 60 months. You 
previously received upper and lower partial dentures on December 8, 2020, less than 60 months prior, which 
were paid for by the Plan. Therefore, you have exhausted the allowable benefit for the requested items in this 
case. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a 
lower partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the end-stage renal disease related services provided on 
August 31, 2022. 
 You asked the Plan to pay for the end-stage renal disease related services. You say that you are requesting 
reconsideration of 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 the end-stage renal 
disease related services provided on August 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an MRI and PT services provided from 
November 30, 2022, to December 5, 2022. 
 
You asked the Plan to waive the coinsurance for an MRI and PT services. You say that you should not have a 
cost share due to reaching your maximum out-of-pocket. 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 each Medicare-covered diagnostic radiology and complex imaging service, including an MRI 
and 20% coinsurance for each Medicare-covered PT visit.  
 
You have been asked to pay $34.91 for an MRI and PT services. Your maximum out-of-pocket (MOOP) was 
not met at the time these claims were processed because the Plan reprocessed a previous claim that resulted in a 
lower enrollee liability. Your MOOP was then met with the processing of these claims. An MRI falls into the 
outpatient diagnostic tests benefit category. The PT services fall 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. 
Therefore, we decided that the Plan does not have to waive the coinsurance for an MRI and PT services 
provided from November 30, 2022, to December 5, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest and computed 
tomography (CT) scan of the abdomen and pelvis 
 
You asked the Plan to pre-approve the CT scans. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the information provided does not meet the criteria for the requested 
services. 
 
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 scans. Our reviewer says that 
the service is medically necessary. Our physician reviewer found the enrollee is a renal transplant recipient and 
is on immune suppression. Review of the chart shows a 50-pound weight loss between May 26, 2022 and April 
27 2023. This profound, unintentional weight loss in the enrollee with immune suppression and is a valid 
indication for the requested CT chest, abdomen and pelvis. 
 
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 scans have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the chest and computed tomography (CT) scan of the abdomen 
and pelvis  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for in-network oxygen equipment 
 
You asked the Plan to waive the coinsurance for in-network oxygen equipment. You say that you were not told 
of this visit cost. 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 20% 
coinsurance for durable medical equipment and other services.  
 
You have been asked to pay a 20% coinsurance for in-network oxygen equipment. This item/service falls 
within the durable medical equipment and other services benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan.  
 ($88.36 x 20% = $17.67) + ($84.50 x 20% =$16.90) = $34.57 coinsurance.  
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 in-network oxygen equipment
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 24, 
2023. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting 
reconsideration of 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 the subsequent nursing 
facility care provided on March 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed with 
more conservation treatments. The Plan denied your request. The Plan says the Intracept procedure is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 Intracept procedure. Our reviewer 
says that the surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no magnetic resonance imaging (MRI) showing only modic changes without facet degenerative 
joint disease or foraminal stenosis. This means that the cause of pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve test strips and lancets. 
 
You asked the Plan to pre-approve test strips and lancets. You say that you would like the requested items 
approved because you have inconsistent blood sugars, and you are pre-diabetic. The Plan denied your request. 
The Plan says you do not meet Medicare criteria. 
 
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 have diabetes. 
Based on this information, we decided that Medicare rules for coverage of test strips and lancets have not been 
met. Therefore, we decided that the Plan does not have to pre-approve test strips and lancets.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit and an emergency room 
(ER) visit. 
 
You asked the Plan to waive the copayment for an urgent care visit and an emergency room (ER) visit. You say 
that if the urgent care provider had not convinced you to go to the ER (for the same tests), you would not have 
this big 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 $25 
copayment for urgently needed services, and a $50 copayment for emergency services, resulting in a total 
copayment of $75.  
 You have been asked to pay a $75 copayment for an urgent care visit and an emergency room (ER) visit. This 
item/service falls within the urgently needed services and emergency 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 copayment for an urgent care visit and an emergency room (ER) visit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist visit provided from 
April 3, 2023, to May 26, 2023. 
 
 
You asked the Plan to waive the copayment for an in-network specialist visit. You say that this happens every 
month, and you want to make sure that everything is correct. 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 $35 
copayment for Physician/Practitioner services, including doctors office visits.  
 
You had three visits, resulting in a $105 total copayment ($35 x 3 = $105). You have been asked to pay a $105 copayment for in-network specialist visits. 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. Therefore, we decided that the Plan does not have 
to waive the copayment for an in-network specialist visit provided from April 3, 2023, to May 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the new patient office visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that you have an established relationship with the 
provider. The Plan denied your request. The Plan says you must receive your 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
new patient office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified maxillofacial prosthesis, by report 
(D5999). 
 
You asked the Plan to pre-approve the unspecified maxillofacial prosthesis, by report. You say that the 
enrollee's dentures did not fit correctly and went back repeatedly to try to have them adjusted. 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 service was exhausted on date of service November 4, 2022. Therefore, 
we decided that the Plan does not have to pre-approve an unspecified maxillofacial prosthesis, by report 
(D5999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care support supplies provided on February 14, 2023. 
 
You asked the Plan to pay for wound care support supplies. You say that this item should be billed separately 
as the patient is in a facility. 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 support 
supplies provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visits. You say that you have seen this provider before. The Plan 
denied your request. The Plan says you must receive your 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visits to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) and heart test 
(93010) provided on March 14, 2022. 
 
You asked the Plan to pay for the emergency department visit and heart test. 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 the emergency department visit (99285) and heart test 
(93010) provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on February 28, 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 February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 20, 2022. 
 
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 January 20, 2022.