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

 
We decided that the Plan does not have to pay for adding a tooth to a partial denture (D5650) for tooth #23 
provided on March 22, 2023. 
 
You asked the Plan to pay for the dental service. You say that the Plan told you that the dental service would be 
covered because a new partial denture would not be covered. The Plan denied your request. The Plan says the 
denial of payment for this service is correct because the bone replacement graft and guided tissue regeneration 
are not covered by the Plan. Also, it was verified that you were told the proper benefits and there was no 
mention of code D5650 during the phone call. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for adding a 
tooth to a partial denture (D5650) for tooth #23 provided on March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 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. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found chronic respiratory failure cannot definitively diagnosed to support home ventilation.  However, the enrollee may benefit from bilevel positive 
airway pressure (BIPAP) with average volume assured pressure support (AVAPS), pending further studies and 
adjustments to her home regimen of therapy and medications. Further data and diagnostic studies are required 
for formal diagnosis and appropriate therapeutic interventions. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the gym membership (S9970) purchased on 
January 1, 2022. 
 
You asked the Plan to issue reimbursement 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 the gym membership purchased 
in this case is not payable as you have not provided valid proof of payment.  
  
 
 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because you did not submit valid proof of 
payment for the gym membership purchased in this case. Therefore, we decided that the Plan does not have to 
issue reimbursement for the gym membership (S9970) purchased on January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine ophthalmologist examination included refraction 
(S0621), contact lens fitting (92310), frames (V2025), vision supply (V2797), and progressive lenses (V2781) 
provided on March 15, 2023. 
 
You asked the Plan to pay for a routine ophthalmologist examination included refraction (S0621), contact lens 
fitting (92310), frames (V2025), vision supply (V2797), and progressive lenses (V2781). You say that this 
location is convenient to your home. You also say that this is the only place you can get frames for a decent 
price and is comfortable with the location. The Plan denied your request. The Plan says that any benefits 
received at a non-network optical provider is not covered. 
 
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 they are received in-network. 
 
We looked at the file and the Plan's rules. The Plan rules say that any benefits received at a non-network optical 
provider are not covered. The record shows that these services were received out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of a routine ophthalmologist examination included 
refraction (S0621), contact lens fitting (92310), frames (V2025), vision supply (V2797), and progressive lenses 
(V2781) have not been met. Therefore, we decided that the Plan does not have to pay for a routine 
ophthalmologist examination included refraction (S0621), contact lens fitting (92310), frames (V2025), vision 
supply (V2797), and progressive lenses (V2781) provided on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve astigmatism-correct function of intraocular lens 
(V2787) provided on February 23, 2023. 
 
You asked the Plan to pre-approve astigmatism-correct function of intraocular lens (V2787) . You say that you 
were not aware prior authorization is needed. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 prior authorization is obtained. 
 
We looked at the file and the Plan's rules. The Plan rules say that if you receive services obtained out-of-
network and were not authorized, you are responsible for paying the full cost of services. The record shows the 
provider is out-of-network and prior authorization was not obtained. Based on this information, we decided that 
the Plan's rules for coverage of astigmatism-correct function of intraocular lens (V2787)  have not been met. 
Therefore, we decided that the Plan does not have to pre-approve astigmatism-correct function of intraocular 
lens (V2787) provided on February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve pontic - porcelain fused to high noble metal (D6240) for tooth 
number 5.  
 
You asked the Plan to pre-approve the pontic for tooth number 5. You say that the records provided support the 
need for the service in dispute. The Plan denied your request. The Plan says that the service in dispute is not 
medically necessary.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the pontic for 
tooth number 5 when the services are medically necessary and reasonable. 
 
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 pontic for tooth number 5. Our 
reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has an 
existing bridge on teeth numbers 4 to 6, pontic tooth number 5. The Plan approved crowns for teeth number 4 
and 6. Since these crowns would be replacing an existing bridge, code D6240 for tooth number 5 should be 
approved also to restore the enrollee's dentition. It would not be in the enrollee's best interest to remove the 
bridge and only place crowns on teeth number 4 and 6 and leaving an open space in number 5 area. This would 
cause teeth numbers 4 and 6 to potentially shift, and the tooth on the lower jaw would potentially shift up. This 
would cause issues with how the enrollee's teeth come together. The requested pontic (D6240) for tooth 
number 5 is medically reasonable and necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontic for tooth number 5 have been met. Therefore, we decided that the 
Plan has to pre-approve pontic - porcelain fused to high noble metal (D6240) for tooth number 5.   
 
  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network cardiac device adjustment 
provided on April 22, 2023. 
 
You asked the Plan to waive the copayment for an in-network cardiac device adjustment. You say that you did 
not see a provider, you just had your device adjusted remotely. There should not be a copay. 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 $30 
copayment for other outpatient diagnostic tests. 
 
You have been asked to pay a $30 copayment for an in-network cardiac device adjustment. This item/service 
falls within the other outpatient diagnostic tests 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 cardiac device adjustment provided on April 22, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on February 17, 2023. 
 
You asked the Plan to pay for outpatient mental health. You say that you say that you were not told the truth by 
the provider. 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 outpatient mental health 
provided on February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
March 5, 2023, and billed with codes 87500, 87641, 87798, G0452, 87481, 87651, and 87653. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on March 5, 2023, and billed with codes 87500, 87641, 87798, G0452, 87481, 87651, and 87653.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on December 5, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency services provided on August 26, 2022. 
 
You asked the Plan to pay for the emergency services. You say that you want this claim to be reviewed 
pursuant to the industry standards for an out-of-network providers (Free standing Emergency) or open it up for 
negotiation. The Plan denied your request. The Plan says as the facility is not enrolled with Medicare with an 
active Centers for Medicare & Medicaid Services (CMS) Certification Number (CCN), the Medicare rule for 
reimbursement of this August 26, 2022, claim has not been met.  
The Plan must follow Medicare rules. Medicare rules say that Medicare payment cannot be made to a provider 
that is not enrolled in the Medicare program. Medicare rules also say that Medicare covers services in an 
emergency department only if the emergency clinic is affiliated with the hospital.  
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. The documentation provided also states that the facility in question is not an actual hospital and has 
no affiliation with a hospital. Therefore, we decided that the Plan does not have to pay for the emergency 
services provided on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342) for tooth 
#20 and #29, a crown (D2740), and core buildup (D2950) for tooth #19 provided by an out-of-network 
provider on February 21, 2023, and April 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that it was medically necessary for you to get the 
dental services done and the rendered dentist was the only dentist that would see you. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodontal scaling and root planing (D4342) for tooth #20 and #29, a crown (D2740), and core 
buildup (D2950) for tooth #19 provided by an out-of-network provider on February 21, 2023, and April 4, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided by an out-of-network provider 
on March 16, 2023. 
 
You asked the Plan to pay for the dental service. You say that the dental service was submitted to the wrong 
coverage. The Plan denied your request. The Plan says the dental service was received from an out-of-network 
provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested item or service is 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 a cleaning (D1110) provided by an out-of-network provider on March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 13, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental service. You say that you been waiting for a denture and you 
cannot chew. 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 partial upper denture (D5225) on December 2, 2022; therefore, your benefit for the 
requested item or service was exhausted on date of service December 2, 2020. Therefore, we decided that the 
Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for procedure code 82465 for date of service February 13, 
2023, minus any cost share requirement. 
 
You asked the Plan to hold you harmless for procedure code 82465. You say that you feel some of the cost of 
the lab work should be covered. The Plan denied your request. The Plan says that the services were billed 
incorrectly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for procedure code 82465 by a contract provider. The file does not show that the Plan 
provided notice that procedure code 82465 would not be covered. Under Medicare rules, this means procedure 
code 82465 is considered approved by the Plan. In addition, the claim receipt sent to the enrollee states that the 
provider was in-network. Therefore, we decided that the Plan has to hold you harmless for procedure code 
82465 for date of service February 13, 2023, minus any cost share requirement.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for optical service allowance (S0590) and miscellaneous vision 
service (V2799) provided on March 8, 2023.  
You asked the Plan to pay for optical service allowance (S0590) and miscellaneous vision service (V2799). 
You say that you think the Plan needs to help a little bit more for the glasses. The Plan denied your request. 
The Plan says that member appears chose an upgraded lens that she would be responsible for. The Plan also 
says that they will pay up to $200 per calendar year combined in and out-of-network routine contacts or 
eyeglasses. 
 
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 up to $200 per calendar year for routine eyewear or contacts. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers up to $200 per calendar year 
for routine eyewear or contacts. The record shows this benefit was exhausted with this service. Based on this 
information, we decided that the Plan's rules for coverage of optical service allowance (S0590) and 
miscellaneous vision service (V2799) have not been met. Therefore, we decided that the Plan does not have to 
pay for optical service allowance (S0590) and miscellaneous vision service (V2799) provided on March 8, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination provided on 
December 01, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that this was your annual 
eye visit. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Medicare-covered examination to diagnose and treat diseases or conditions of the eye. 
 
You have been asked to pay a $40 copayment for a medical eye examination. This item/service falls within the 
Medicare-covered examination to diagnose and treat diseases or conditions of the eye 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 record shows that this 
was a diagnostic, medical eye examination, not a routine one. Therefore, we decided that the Plan does not 
have to waive the copayment for a medical eye examination provided on December 01, 2022.