Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, and related services provided on March 8, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit, and related services. You say that the provider was not aware that 
coverage had changed. The Plan denied your request. The Plan says enrollees must receive their care from a 
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
items/services 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 the office visit, and related services provided on 
March 8, 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 a porcelain fused to noble metal crown (D2752) provided on 
December 6, 2022. 
 
You asked the Plan to pay for porcelain fused to noble metal crown (D2752). You say that your Plan covers 
restorations for cavities. You also say that given the conditions, your dentist determined that the best way to 
treat and save the tooth was to clean out the area of decay, remove the old filling, and place a crown on the 
tooth. The Plan denied your request. The Plan says this procedure is not covered under your dental 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 
porcelain fused to noble metal crown (D2752) provided on December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an intraoral 
comprehensive x-ray (D0210), a prophylaxis (D1110), a topical application of fluoride varnish (D1206), and an 
occlusal guard (D9944) provided on April 18, 2023. 
 
You asked the Plan to pay for a comprehensive oral evaluation (D0150), an intraoral comprehensive x-ray 
(D0210), a prophylaxis (D1110), a topical application of fluoride varnish (D1206), and an occlusal guard 
(D9944). You say that there was a misleading by the Plan agent to specify what the coverage is. The Plan 
denied your request. The Plan says the members policy does not include supplemental/routine dental benefits. 
The Plan also says that their records indicate the member did not contact the Plan prior to the date of service to 
verify dental benefits and provider eligibility. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150), an intraoral comprehensive x-ray (D0210), a prophylaxis (D1110), a topical application of fluoride 
varnish (D1206), and an occlusal guard (D9944) provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and an x-ray 
provided on March 20, 2023, and a specialist office visit provided on April 20, 2023. 
 
You asked the Plan to waive the copayments for the specialist office visits and an x-ray. You say that you 
should not be charged for a diabetic checkup. 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 $45 
copayment for each specialist visit for in-network Medicare-covered services. Your contract with the Plan also 
clearly says that you must pay a $60 copayment for an in-network Medicare-covered x-ray. 
 
You have been asked to pay a $45 copayment for each specialist office visit provided on March 20, 2023, and 
April 20, 2023. You have been asked to pay a total of $90 for the specialist office visits ($45 copayment + $45 
copayment = $90). These items/services fall within the physician/practitioner services, including doctors 
office visits benefit category. You have also been asked to pay a $60 copayment for the x-ray provided on 
March 20, 2023. This item/service falls within the outpatient diagnostic tests and therapeutic services and 
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. Therefore, we decided that the Plan does not have to waive the copayments for a specialist office visit and 
an x-ray provided on March 20, 2023, and a specialist office visit provided on April 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 continuous glucose monitor 
(CGM) system. 
 
You asked the Plan to pre-approve the FreeStyle Libre 14 CGM system.. You say that the medical records 
support the medical necessity for the CGM.  The Plan denied your request. The Plan says the enrollee is not on 
insulin and does not have documentation of problematic hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 FreeStyle Libre 14 CGM system. 
Our reviewer says that the CGM is not medically necessary. Our physician reviewer found coverage criteria 
require low blood glucose sugar or insulin use for CGM coverage. Although the enrollee is not checking blood 
glucose sugar, and the prescribed CGM would help monitor blood glucose sugar more and perhaps impact their 
diet and blood glucose control, the coverage criteria are not met. The enrollee is not on medications that would 
typically cause problematic low blood glucose sugar and there is no indication that they will or is treated with 
insulin. 
 
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 FreeStyle Libre 14 CGM system. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a FreeStyle Libre 14 continuous glucose monitor (CGM) system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary to help the 
enrollee return to prior level of function. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar fusion surgery at L5-S1. 
 
You asked the Plan to pre-approve a lumbar fusion surgery. You say that the enrollee has failed to respond to 
conservative treatments including nonsteroidal anti-inflammatories (NSAIDS), 
chiropractic treatment, a home exercise program and epidural steroid injections without success. The Plan 
denied your request. The Plan says based on the Plan's internal medical criteria, this surgery 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 a lumbar fusion surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Detailed documentation is not evident regarding potential impending/inevitable temporary intra-operative instability. There are limited large-scale, long-term references showing the safety and 
efficacy of the requested surgery in this clinical setting. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
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 lumbar fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar fusion surgery at L5-S1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital, monaural hearing aids (V5257) provided on April 21, 
2023. 
 
You asked the Plan to pay for digital, monaural hearing aids (V5257). You say that the explanation of benefits 
(EOB) showed that the Plan rejected all payment. You also say you learned that the Plan coverage for hearing 
aids changed this year, and the rendering provider is not a part of the hearing vendor program. The Plan denied 
your request. The Plan says hearing aids are not a covered benefit unless provided by a contracted Plan vendor. 
 
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 the hearing aids are obtained through an in-network Plan 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 digital, monaural hearing aids (V5257) have not been met. Therefore, we decided that the Plan 
does not have to pay for digital, monaural hearing aids (V5257) provided on April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical placement of implant body (D6010) for teeth 
numbers 13, and 30 provided on April 18, 2023. 
 
You asked the Plan to pay for a surgical placement of implant body (D6010) for teeth numbers 13, and 30. You 
say that this procedure was done to replace over 30 year old broken bridges, which had caused recurring 
infections and much pain. The Plan denied your request. The Plan says this implant service is not a covered 
benefit 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. 
 
 
  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 surgical 
placement of implant body (D6010) for teeth numbers 13, and 30 provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the principal care management services provided on March 
17, 2023, by an OON provider.  
 
You asked the Plan to pay for the care management services. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says this service was not authorized. 
 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 the principal care management services provided 
on March 17, 2023, 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 OON provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service was not approved. 
 
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 OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on November 2, 2022. 
 
You asked the Plan to pay for the ambulance services and ground mileage. You say that the enrollee is bed-
confined, frail, debilitated, and with extreme muscle atrophy. You also say that there is risk for falling out of 
wheelchair while in motion as the enrollee has a left below the knee amputation. The Plan denied your request. 
The Plan says the records do not show the enrollee is unable to transfer, is completely bed-bound or have any 
acute conditions which require continuous monitoring.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance services and ground mileage. 
Our reviewer says that the ambulance transport services were not medically necessary.  Our physician reviewer found the transportation via ambulance upon hospital discharge was not medically 
necessary. The enrollee did not require the expertise of trained personnel or the equipment available only on an 
ambulance in order to effectuate a safe transport. Transportation could have been provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering the enrollee's condition. A prudent 
layperson would not believe that immediate medical attention was required for someone who was being 
discharged from the hospital. 
 
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 ambulance services and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on November 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210), or pay more for a comprehensive 
periodontal evaluation (D0180), and an adult prophylaxis (D1110) provided on May 2, 2023. 
 
You asked the Plan to pay for an intraoral x-ray (D0210), and pay more for a comprehensive periodontal 
evaluation (D0180), and an adult prophylaxis (D1110). You say that you were never told that this was not an 
in-network provider. The Plan denied your request. The Plan says an intraoral x-ray (D0210) is not a covered 
benefit with the Plan. The Plan also says that you are responsible for any charged amount above the Plans 
cost-sharing amount for a comprehensive periodontal evaluation (D0180), and an adult prophylaxis (D1110) 
when your services are received from an out-of-network provider.  
 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, intraoral x-rays (D0210) are not among 
those covered under this benefit.  
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for a comprehensive periodontal evaluation (D0180), and an adult prophylaxis (D1110). 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 for an intraoral x-ray (D0210), or pay more for a comprehensive periodontal 
evaluation (D0180), and an adult prophylaxis (D1110) provided on May 2, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, non-emergency transport, and 
ground mileage provided on March 12, 2022. 
 
You asked the Plan to pay for the ambulance services and ground mileage. You say that the claim is not a 
duplicate and have submitted the ambulance report for the transports. The Plan denied your request. The Plan 
says that this is a duplicate claim that has already been considered for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not included any evidence of paying the claim. The 
Plan has not substantiated their denial reason.  Therefore, we decided that the Plan has to pay for ambulance 
service, basic life support, non-emergency transport, and ground mileage provided on March 12, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 17, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell 
and were unable to be lifted by your wife, so the emergency medical services were called to lift you up from 
floor. You also say that you feel the service should not be denied. The Plan denied your request. The Plan says 
these services are not a covered benefit.  
 
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 February 17, 2023. 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 provided on February 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital bed (E0250, E1399) purchased on August 17, 
2022. 
 
You asked the Plan to pay for the hospital bed. You say that the items should be covered. The Plan denied your 
request. The Plan says this item was obtained through a provider that it not enrolled in Medicare and without a 
prescription. 
 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. Durable Medical Equipment, Prosthetic, and Orthotic Supplies 
(DMEPOS) require a written order/prescription from the treating practitioner. 
 
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 hospital bed (E0250, E1399) 
purchased on August 17, 2022.