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

 
We decided that the Plan does not have to reimburse for hearing aids provided on June 30, 2023. 
 
You asked the Plan to reimburse for hearing aids. You say that these hearing aids cost less and last at least five 
years. The Plan denied your request. The Plan says the service sought or obtained by the member was or will 
be rendered by a provider who is not under contract with the Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you go through the Plan hearing specific provider or vendor.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse for 
hearing aids provided on June 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient services in a psychiatric hospital 
provided on November 15, 2022, to November 20, 2022. 
 
You asked the Plan to waive the copayment for inpatient services in a psychiatric hospital. You say that you 
disagree with the 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 $440 
copayment for inpatient services in a psychiatric hospital. 
 
You have been asked to pay a $440 copayment for inpatient services in a psychiatric hospital. This item/service falls within the inpatient services in a psychiatric hospital 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 amount you owe is $2,200 ($440 x 5 days 
= $2,200). Therefore, we decided that the Plan does not have to waive the copayment for inpatient services in a 
psychiatric hospital provided on November 15, 2022, to November 20, 2022.
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 a CGM. You say that the enrollee would like this CGM so she can stop 
pricking her finger. The Plan denied your request. The Plan says the medical criteria for a CGM have not been 
met. 
 
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 a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, intraoral x-rays, and periodontal 
maintenance (D0230, D0120, D0220, D4910) provided on June 6, 2022, to August 24, 2022. 
 
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 a periodic 
oral evaluation, intraoral x-rays, and periodontal maintenance (D0230, D0120, D0220, D4910) provided on 
June 6, 2022, to August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 14, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that their original decision to deny payment was correct.  
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on August 14, 2023, by an 
out-of-network (OON) provider.
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 
multiple 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 requested Intracept procedure is not considered medically reasonable and necessary. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) showing only Modic changes 
without facet degenerative joint disease or stenosis. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the neuroplasty procedure provided on June 
13, 2023. 
 
You asked the Plan to waive the copayment for the neuroplasty procedure. You say that this was an 
unsuccessful 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 $250 
copayment for outpatient surgery and other medical services provided at ambulatory surgical centers. 
 
You have been asked to pay a $250 copayment for the neuroplasty procedure. This item/service falls within the 
outpatient surgery and other medical services provided at ambulatory surgical centers 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 the neuroplasty procedure provided on June 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
June 20, 2023. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic tests. You say that you disagree with 
the 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 $100 
copayment for outpatient diagnostic tests/Medicarecovered diagnostic radiologyservices. 
 
You have been asked to pay a $100 copayment for an outpatient diagnostic tests. This item/service falls within 
the outpatient diagnostic tests/Medicarecovered diagnostic radiologyservices 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 outpatient diagnostic tests provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
16, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
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 $35 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for a specialist office visit. This item/service falls within the in-
network 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 a specialist office visit provided on June 16, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dopamine Transporter Scan - Single Photon Emission 
Computed Tomography (DAT-SPECT) scan. 
 You asked the Plan to pre-approve a DAT-SPECT scan. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the single photon emission computed tomograph 
(SPECT) acquires information on the concentration of radionuclides introduced into the patient's body. 
 
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 a DAT-SPECT scan. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found provided records in this case do not 
document concern for a stress fracture or spondylosis or infection (e.g., discitis) or tumor (e.g., osteoid 
osteoma) or a need to analyze blood flow to an organ, as in the case of myocardial viability or to differentiate 
ischemic heart disease from dilated cardiomyopathy, as is required by the NCD for coverage. The available 
evidence suggests that the overall accuracy of DaTscan for parkinsonian syndromes is equal to but not better 
than the accuracy of a carefully obtained clinical diagnosis. Provided records do not document concern for 
essential tremor in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a DAT-SPECT scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dopamine Transporter Scan - Single Photon Emission Computed Tomography 
(DAT-SPECT) scan.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of heart with 
evaluation of blood vessel calcium. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the requested imaging is not a covered service. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the CT scan, is being requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-
approve a computed tomography (CT) scan of heart with evaluation of blood vessel calcium.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified adjunctive service (D9999). 
 
You asked the Plan to pre-approve D9999. You say that you need this dental work. The Plan denied your 
request. The Plan says this service is not 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 an 
unspecified adjunctive service (D9999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you have been on Dexcom for years and you would 
like a new model. The Plan denied your request. The Plan says only the preferred brand products listed in the 
EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 continuous 
glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ambulance services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the ambulance services. You say that you needed a ride to dialysis because 
you live in a rural area. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 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 ambulance services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy visits. 
 
You asked the Plan to pre-approve massage therapy visits. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says massage therapy and acupuncture visits are 
limited to 6 visits per calendar year combined. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the x-ray and an office visit on August 23, 
2023.  
 
You asked the Plan to waive the copayments for the x-ray and an office visit. You say that you never had an x-
ray copay before and should not be responsible for the copays. 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 
copayment for most x-rays and ultrasounds except as specified. You must pay a $35 copayment per visit to a 
specialist. For both services it's $20 + $35 = $55. Therefore, results in the total cost sharing amount of $55. 
 
You have been asked to pay a $20 copayment for the x-ray and a $35 copayment for an office visit. This 
item/service falls within the outpatient diagnostic tests and therapeutic services and supplies and 
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 copayments for the x-ray and an office visit on August 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapies. 
 
You asked the Plan to pre-approve massage therapies. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the enrollee has had 8 out of those 10 approved 
visits. Additional visits are denied as they are not covered. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapies.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an OON provider.  
 
You asked the Plan to pre-approve the mental health services. You say that you are requesting reconsideration 
of the denied authorization. The Plan denied your request. The Plan says this service is available with in-
network providers. 
 
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 mental health services to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you need to see a female urologist for a second 
opinion.  The Plan denied your request. The Plan says the Plan does not cover out-of-network services rendered 
with the exceptions of certain situations.  
 
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 
an office visit 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 laboratory service and the emergency room visit provided 
on June 02, 2023. 
 
You asked the Plan to pay for the laboratory service and the emergency room visit. 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 laboratory service 
and the emergency room visit provided on June 02, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on June 06, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service 
provided on June 06, 2023.