Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 
15, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on October 10, 2022. 
 
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 office visit (99202) provided on October 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 
30, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutments (D6060) for tooth #30 and #31. 
 
You asked the Plan to pre-approve the dental services. You say that you just found out that there are 
restrictions, and the Plan only authorizes 2 per year. The Plan denied your request. The Plan says your benefit 
for the requested items or services 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 authorized 2 abutments (D6060) for tooth #18 and #19 on January 13, 2023, and 2 surgical 
access to an implant body (D6011) for tooth #30 and #31 on February 28, 2023; therefore, your benefit for the 
requested items or services was exhausted on date of authorization of February 28, 2023. Therefore, we 
decided that the Plan does not have to pre-approve abutments (D6060) for tooth #30 and #31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 30, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on April 14, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that wound care supplies are a separately billable 
expense that does not require authorization or referral. 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 April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional acupuncture visits. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
 
  
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case. 
 
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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that there does not appear to 
be sustained significant improvement in pain. Therefore, the requested services are deemed not medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and the Plans rules. Based on this information, we decided that 
the Plans rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 5 additional acupuncture visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on June 15, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this should 
be covered as an emergency service. You say that you slipped, badly cut your leg, are on blood thinners, and 
began to bleed profusely. The Plan denied your request. The Plan says you were treated and not transported. 
 
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 June 15, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve the occlusal guard. You say that your dentist advised that your grit your 
teeth at night and it is causing erosion as well as discomfort you. The Plan denied your request. The Plan says 
this service is not covered under the benefit package. 
 
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 pre-approve an 
occlusal guard  hard appliance, full arch (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - one to three teeth 
per quadrant (D4342). 
 
You asked the Plan to pre-approve the dental services. You say that your dentist has recommended deep 
cleaning and you'd like to get approval for another deep cleaning although it's within the 3 year timeframe. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 12, 2021. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing - one to 
three teeth per quadrant (D4342).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a periodic oral evaluation (D0120) and a 
cleaning (D1110) provided by an out-of-network provider on January 17, 2023. 
 You asked the Plan to waive the coinsurance for the dental services. You say that you were not informed that 
the provider was an out-of-network provider. 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 non-Medicare covered preventive dental services when the services are provided by an out-of-
network provider. The total amount for the periodic oral evaluation was $62 with a coinsurance amount of 
$12.40 ($62 total x 20% coinsurance). The total amount for the cleaning was $111 with a coinsurance amount 
of $22.20 ($111 total x 20% coinsurance). The total coinsurance amount was $34.60 ($12.40 coinsurance + 
$22.20 coinsurance). 
 
You have been asked to pay a 20% coinsurance for the dental services. This item/service falls within 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 a periodic oral evaluation 
(D0120) and a cleaning (D1110) provided by an out-of-network provider on January 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
 You asked the Plan to pre-approve the additional routine transportation. You say that you are requesting 
additional routine transportation for a therapy appointment that is over the 60 mile limit. You also say that this 
is the only physical therapist for this type of therapy. The Plan denied your request. The Plan says trips over the 
limit are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when routine transportation to plan approved health-related 
locations is covered for up to 100 one-way trips per calendar year (limited to ground transportation only). 
Member has the option to use up to 24 of the 100 one-way trips for non-health related services (Plan 
restrictions apply). Each one-way trip must not exceed 60 miles based on the most efficient route. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite crown (D2710) for tooth #6, 
#7, #8, #9, #10, and #11. 
 
You asked the Plan to pre-approve a crown. You say that this was approved in 2022, and not it is being denied. 
You say that you do not understand. The Plan denied your request. The Plan says this dental service is no 
longer a covered benefit. 
 
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 pre-approve a 
resin-based composite crown (D2710) for tooth #6, #7, #8, #9, #10, and #11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the chiropractor visits provided from October 
12, 2022, to December 19, 2022. 
 
You asked the Plan to waive the copay for the chiropractor visits. You say that your agent advised that you 
could be reimbursed for these visits with your Wallet Benefit. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. The Plan also says that you are not eligible to submit for reimbursement 
under the Wallet Benefit for services that are already covered under your medical benefits. 
 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 
copayment for Chiropractic services.  
 
You have been asked to pay a $20 copayment for the chiropractor visits. These services fall within the 
Chiropractic services benefit category, and are a Medicare-covered benefit. 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. Your Wallet Benefit does not reimburse you for 
services that are covered under your medical benefits. These visits have been billed and covered by your plan 
under your medical benefits applying the correct cost share amount for each visit. Therefore, we decided that 
the Plan does not have to waive the copay for the chiropractor visits provided from October 12, 2022, to 
December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to waive the cost share for the capsaicin patch and the podiatry office 
visit provided on January 9, 2023. 
 
You asked the Plan to waive the cost share for the capsaicin patch and the podiatry office visit. You say that 
you were never told there would be a 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 10% 
coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must 
pay a $15 copayment for each Medicare-covered podiatry visit. 
 
You have been asked to pay $181.44, which is 10% coinsurance of the allowed amount for the capsaicin patch 
($1,814.40 allowed amount x 10% = $181.44). This item/service falls within the Medicare Part B prescription 
drugs benefit category. You have also been asked to pay a $15 copayment for the podiatry office visit. This 
item/service falls within the podiatry 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 cost share 
for the capsaicin patch and the podiatry office visit provided on January 9, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 You asked the Plan to pre-approve the additional routine transportation trips. You say that the enrollee does not 
have transportation to his appointments. The Plan denied your request. The Plan says at the moment of the 
evaluation in appeal, the evidence received from the provider shows that the enrollee consumed thirty-four (34) 
of the thirty-four (34the additional trips in excess of thirty-four (34). The additional one-way trips are non-
covered by the health plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 34 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain fused to predominantly base metal 
(D6241 x2), and retainer crown - porcelain fused to predominantly base metal (D6751 x5). 
 
You asked the Plan to pre-approve the dental services. You say that you requested a dental service and it was 
partially approved. You also say that it should be approved because it is extremely necessary and you are very 
upset since it is the first time that you have requested a dental service with the Plan.  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 that the Plan approved the requested services up to your benefit limit at the time of the initial request. 
Therefore, we decided that the Plan does not have to pre-approve a pontic - porcelain fused to predominantly 
base metal (D6241 x2), and retainer crown - porcelain fused to predominantly base metal (D6751 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for detailed and extensive oral evaluation - problem focused, by 
report (D0160), cone beam CT capture and interpretation for TMJ series including two or more exposures 
(D0368), occlusal orthotic device, by report (D7880) and the Plan does not have to pay more for CT, 
maxillofacial area; without contrast material (70486) and office o/p new mod 45-59 min (99204) provided on 
August 31, 2022, to December 7, 2022. 
 
You asked the Plan to pay for dental services. You say that you are expecting reimbursement for the services 
you paid for upfront. The Plan denied your request. The Plan says these services are not covered under your 
Plan. 
 
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. Enrollees must pay 40% 
coinsurance for covered out-of-network dental services. This benefit includes only those items and services 
specifically listed in your Plan contract. Detailed and extensive oral evaluation - problem focused, by report 
(D0160), cone beam CT capture and interpretation for TMJ series including two or more exposures (D0368) 
and occlusal orthotic device, by report (D7880) are not covered under the Plans dental services. 
 
The allowed amounts of the covered dental services total $304.69, resulting in a coinsurance amount of 
$121.87 and Plan payment amount $182.82. 
 
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 pay more for CT, maxillofacial area; without contrast material (70486) 
and office o/p new mod 45-59 min (99204). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0160, D0368 and 
D7880 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for detailed and extensive oral evaluation - problem focused, by report (D0160), cone beam CT capture and 
interpretation for TMJ series including two or more exposures (D0368), occlusal orthotic device, by report 
(D7880) provided on August 31, 2022, to December 7, 2022.