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

 
We decided that the Plan does not have to pay for a medical eye examination (92014) and progressive lenses 
(V2781) provided on June 27, 2023.  
You asked the Plan to pay for a medical eye examination (92014) and progressive lenses (V2781). You say that 
you were not aware you could not use an out-of-network and not get reimbursed for at least some of what you 
spent for the services. The Plan denied your request. The Plan says your benefit Plan does not cover these out-
of-network vision care services or materials. 
 
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 you use an in-network Plan vision provider.. 
 
We looked at the file and the Plan's rules. The Plan rules say you must use a Plan vision provider for this 
benefit. Based on this information, we decided that the Plan's rules for coverage of a medical eye examination 
(92014) and progressive lenses (V2781) have not been met. Therefore, we decided that the Plan does not have 
to pay for a medical eye examination (92014) and progressive lenses (V2781) provided on June 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that without non-invasive ventilation (NIV) 
therapy, the enrollee is at high risk for hospital readmission and potentially life-threatening exacerbations. The 
Plan denied your request. The Plan says the request for a home mechanical ventilator with auto-expiratory 
positive airway pressure that could be delivered by BiPAP is not covered.  
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary. This enrollee has a history of severe obesity, obstructive sleep apnea, heart failure with 
preserved ejection fraction, and pulmonary hypertension. There is a history of asthma/COPD, although 
pulmonary function tests in 2022 showed severe restrictive disease, without evidence for obstruction or air 
trapping. The enrollee was recently hospitalized for an exacerbation of congestive heart failure, and arterial 
blood gasses (ABGs) were consistent with acute on chronic hypercarbic respiratory failure. There is no 
diagnosis of thoracic restrictive disease or neuromuscular disease. This enrollee may benefit from BiPAP with 
average volume assured pressure support (AVAPS) during sleep as an outpatient. The records do not show this 
has been tried as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 10, 2023, to July 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 annual dental allowance amount for covered dental benefits was exhausted on date of service June 
1, 2023. Therefore, we decided that the Plan does not have to pay for dental services provided on July 10, 2023, 
to July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each diabetic supplies provided on June 
17, 2023, to August 19, 2023. 
 
You asked the Plan to waive the coinsurance for each diabetic supplies. You say that you want to know why 
the plan is over charging you like this. 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 each diabetic supplies. 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 $212.34 ($296.72 allowed amount x 
20% = $59.34 and $255.01 allowed amount x 20% = $51 [$51 coinsurance x 3 visits = $153]). Therefore, we 
decided that the Plan does not have to waive the coinsurance for each diabetic supplies provided on June 17, 
2023, to August 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-cement or re-bond fixed partial denture (D6930) provided 
on June 28, 2023. 
 
You asked the Plan to pay for re-cement or re-bond fixed partial denture. You say that this should be covered. 
The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for re-cement 
or re-bond fixed partial denture (D6930) provided on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tympanometry (impedance testing) (92567) and the 
comprehensive audiometry threshold evaluation and speech recognition test (92557) rendered by the out-of-
network (OON) provider on June 2, 2023.  
 
You asked the Plan to pay 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 services 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. 
 
  
 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.  
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the tympanometry (impedance testing) (92567) and the comprehensive 
audiometry threshold evaluation and speech recognition test (92557) rendered by the out-of-network (OON) 
provider on June 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), intraoral  comprehensive series of radiographic images (D0210), topical application of 
fluoride varnish (D1206),  prophylaxis - adult (D1110), and adjunctive pre-diagnostic test that aids in detection 
of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy 
procedures (D0431) provided on July 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you verified with the plan and the provider that 
your appointment would be covered by your Medicare policy.  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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the adjunctive pre-diagnostic test is not 
among those covered under this benefit. The record also 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 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 comprehensive oral evaluation - new or 
established patient (D0150), intraoral  comprehensive series of radiographic images (D0210), topical 
application of fluoride varnish (D1206),  prophylaxis - adult (D1110), and adjunctive pre-diagnostic test that 
aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include 
cytology or biopsy procedures (D0431) provided on July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extra spinal chiropractic manipulative treatment and the 
office visit provided by a chiropractor on December 12, 2022, to December 22, 2022. 
 
You asked the Plan to pay for extra spinal chiropractic manipulative treatment and the office visit. You say that 
the coverage handbook says you have coverage. The Plan denied your request. The Plan says that the only 
covered chiropractic service is manual manipulation of the spine. 
 
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 extra spinal chiropractic manipulative treatment and the office visit 
provided by a chiropractor on December 12, 2022, to December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acoustic compressive therapy provided by a chiropractor on 
May 18,2023, to July 6, 2023. 
 
You asked the Plan to pay for acoustic compressive therapy. You say that you began to improve enough to 
regain strength and flexibility after receiving the treatment. The Plan denied your request. The Plan says that 
the only covered chiropractic service is manual manipulation of the spine. 
 
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 acoustic compressive therapy provided by a chiropractor on May 18,2023, to 
July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for an eye examination (92014), a determination of 
refractive state (92015), contact lens fitting (92310), contact lenses (V2522) and other unlisted ophthalmologic 
procedure (92499) provided on July 10, 2023. 
 
You asked the Plan to reimburse for an eye examination (92014), a determination of refractive state (92015), 
contact lens fitting (92310), contact lenses (V2522) and other unlisted ophthalmologic procedure (92499). You 
say that you submitted documents that say under "network" it shows "any" for services. You also say that you 
believed everything would be taken care of. The Plan denied your request. The Plan says your Plan does not 
cover these services when you see an out-of-network provider. 
 
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 the services are rendered through a Plan vision care provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that the requested services are covered when 
performed by a Plan vision care provider. Based on this information, we decided that the Plan's rules for 
coverage of an eye examination (92014), a determination of refractive state (92015), contact lens fitting 
(92310), contact lenses (V2522) and other unlisted ophthalmologic procedure (92499) have not been met. 
Therefore, we decided that the Plan does not have to reimburse for an eye examination (92014), a 
determination of refractive state (92015), contact lens fitting (92310), contact lenses (V2522) and other unlisted 
ophthalmologic procedure (92499) provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811), manual therapy 
(97140), and the infrared therapy (97026) provided on May 8, 2023 and June 16, 2023. 
 
You asked the Plan to pay 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 these services are not payable as the provider 
is not enrolled in the Medicare program.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program.  
  
 
 
 
Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811), 
manual therapy (97140), and the infrared therapy (97026) provided on May 8, 2023 and June 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 26, 
2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says enrollees generally must receive their care from a 
network provider. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care provided on April 26, 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 dental services provided on February 27, 2020. 
 
You asked the Plan to pay for dental services. You say that you had several things going on in the last couple of 
years. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for dental services was not filed until May 30, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for dental services provided on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each life vest service provided on April 
28, 2023, to May 28, 2023. 
 
You asked the Plan to waive the coinsurance for each life vest service. You say that you say that you dont 
feel that its right that your being charged for this considering you only were able to wear it once and even 
then, it did notfunction properly and the provider who prescribed it did not instruct you appropriately. 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 each life vest service. 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 $1,253.60 ($3,134 allowed amount x 
20% = $626.80 [$626.80 coinsurance x 2 visits = $1,253.60]). Therefore, we decided that the Plan does not 
have to waive the coinsurance for each life vest service provided on April 28, 2023, to May 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), a core build-up (D2950), and endodontic therapy (D3310) provided on March 8, 2023, to March 15, 2023.

You asked the Plan to pay for D2740, D2950, and D3310. You say that you feel like you were given incorrect information. The Plan denied your request. The Plan says these services have been correctly denied.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 crown (D2740), a core build-up (D2950), and endodontic therapy (D3310) provided on March 8, 2023, to March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 
2, 2023. 
 
You asked the Plan to pay for the dental service. You say that the provider never called the Plan and it should 
be their responsibility to verify the x-rays before they were taken. The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a panoramic radiographic image (D0330) on January 14, 2022; therefore, your benefit 
for the requested item or service was exhausted on the date of service of January 14, 2022. Therefore, we 
decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 2, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-discountable items and warranties (V2797) provided on 
August 2, 2023. 
 
You asked the Plan to pay for non-discountable items and warranties (V2797). You say that this provider is 
listed as a provider that the Plan covers. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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 only routine eye examinations and corrective eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that this is a primary vision care benefit intended 
to cover only routine eye examinations and corrective eyewear. Non-discountable items and warranties 
(V2797) are excluded from this benefit. Based on this information, we decided that the Plan's rules for 
coverage of non-discountable items and warranties (V2797) have not been met. Therefore, we decided that the 
Plan does not have to pay for non-discountable items and warranties (V2797) provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an extraction (D7140) 
for tooth #23, #24, and #25 provided on June 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that the card that you have said that the services are 
covered at 20%. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because the limited oral evaluation and extractions are not covered by the 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. 
 
  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 limited 
oral evaluation (D0140) and an extraction (D7140) for tooth #23, #24, and #25 provided on June 15, 2023.