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

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visits. You say that you want to continue seeing this out-of-
network provider. The Plan denied your request. The Plan says you must get your care from 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 office visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom g6 continuous glucose monitor sensor 
(CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
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 have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Dexcom g6 continuous glucose monitor sensor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781), frames (V2020), lenses 
(V2783), and antireflective coating (V2750) provided on March 16, 2023. 
 
You asked the Plan to pay for progressive lenses (V2781), frames (V2020), lenses (V2783), and antireflective 
coating (V2750). You say that the original receipt from the vendor is enclosed. You also say it does not match 
this explanation of benefits. The Plan denied your request. The Plan says after your Plan coverage was applied, 
that left a $183.20 coinsurance as member responsibility. The Plan also says they tried to contact you several 
times to provide additional information, however, there was no response or call back. 
 
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 toward the purchase and fitting of eyeglasses and pair of lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $200 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). The record shows this 
benefit was exhausted with this service. Based on this information, we decided that the Plan's rules for 
coverage of progressive lenses (V2781), frames (V2020), lenses (V2783), and antireflective coating (V2750) 
have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781), 
frames (V2020), lenses (V2783), and antireflective coating (V2750) provided on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), the intraoral 
radiographic image (D0210), and a cleaning (D1110) provided by an out-of-network provider on March 29, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that the website was misleading and you 
thought the provider would be for preventive maintenance. The Plan denied your request. The Plan says you 
are responsible for any charged amount above the Plans cost-sharing amount 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. 
 
The total amount billed for the comprehensive oral evaluation (D0150) was $111 and the total allowed amount 
was $45.27 leaving a difference of $65.73 ($111 billed - $45.27 allowed). The total amount billed for the 
intraoral radiographic image (D0210) was $160 and the total allowed amount was $86.12 leaving a difference 
$73.88 ($160 billed - $86.12 allowed). The total amount billed for the cleaning (D1110) was $112 and the total 
allowed amount was $59.72 leaving a difference of $52.28 ($112 billed - $59.72 allowed). The total difference 
for all the dental services was $191.89 ($65.73 difference + $73.88 difference + $52.28 difference). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), 
the intraoral radiographic image (D0210), and a cleaning (D1110) provided by an out-of-network provider on 
March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning and amalgam (D2140, D1110) provided on 
January 7, 2023. 
 
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 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 a cleaning and amalgam (D2140, D1110) provided on January 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on 
April 3, 2023. 
 
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 an 
unspecified preventive procedure (D1999) provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) provided on 
February 14, 2023. 
 
You asked the Plan to pay for the cone beam CT scan. 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 cone 
beam computed tomography (CT) provided on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visits. You say that the enrollee needs additional visits. 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 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 office visits to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic (D6740), and 
pontic - porcelain/ceramic (D6245). 
 
You asked the Plan to pre-approve the retainer crown - and pontic - porcelain/ceramic. You say that these 
services are medically necessary because you have two lumps called tori inside of your gums. The Plan denied 
your request. The Plan says the retainer crowns and pontic are not covered under your benefit 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 pre-approve a 
retainer crown - porcelain/ceramic (D6740), and pontic - porcelain/ceramic (D6245).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional miles. You say that you need the additional miles to see an 
endodontist for a bad root problem. You also say that this is the only in-network provider near you to provide 
the dental services with endodontics and you really need this ride. The Plan denied your request.  The Plan says there is a limit of 30 miles per one-way trip. The Plan also says that there are 26 endodontists 
within 30 miles of your zip code. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation miles.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for procedure code L8691 provided on July 27, 2022. 
 
You asked the Plan to pay for procedure code L8691. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, code L8691 has a Practitioner Medically Unlikely Edit (MUE) of 1, which means 1 unit can be 
billed for this code per date of service. This code represents the sound processor for an implanted cochlear 
device. Per Medicare guidelines, implanted DME and supplies for the implanted equipment are billed to the 
local carrier and not to the DMERC. Code L8691 is separately payable in this case. Therefore, we decided that 
the Plan has to pay for procedure code L8691 provided on July 27, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for  a prophylaxis dental service provided by 
an OON provider on March 16, 2023. 
 
You asked the Plan to waive the coinsurance for  a prophylaxis dental service. You say that you were told the 
provider was in network. 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 50% 
coinsurance for out of network dental services.  
 
You have been asked to pay 50% coinsurance for a prophylaxis dental service. This item/service falls within 
the out of network dental services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for  
a prophylaxis dental service provided by an OON provider on March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6545 that 
were issued on March 7, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that this code is not the best code to use but 
the enrollee has done manual drainage and has had some wound issues. You also say that the enrollee has had 
this issue for several years. The Plan denied your request. The Plan says there is no documentation of a surgical 
wound, debridement, or ulcers. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pay for the compression stockings identified 
with code A6545 that were issued on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  mandibular partial denture (D5214) provided on January 26, 
2023. 
 
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 your $2,000 annual maximum has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pay for  mandibular partial denture (D5214) provided on January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the ankle orthosis (L1902) provided on March 1, 2023. 
 
You asked the Plan to pay more for the ankle orthosis (L1902). You say that you would like to be refunded for 
the cost of the medical equipment. 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 in-network durable medical equipment. 
  You have been asked to pay 20% coinsurance for the ankle orthosis (L1902). 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 $12.33 ($61.66 allowed amount x 20% = 
$12.33). Therefore, we decided that the Plan does not have to pay more for the ankle orthosis (L1902) provided 
on March 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport services and ground mileage provided 
on July 19, 2021. 
 
You asked the Plan to pay for the ambulance transport services and ground mileage. You say that you are 
seeking resolution and payment for this claim. You also say that the enrollee had two or more services provided 
on this date of service. The Plan denied your request. The Plan says the claim was submitted past the timely 
filing limit. 
 
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 the ambulance transport services and ground mileage was not filed until 
December 9, 2022. 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 ambulance transport services and 
ground mileage provided on July 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network inpatient stay provided from 
January 6, 2023, to January 9, 2023. 
 
You asked the Plan to waive the copayment for an in-network inpatient stay . You say that you should not have 
to pay a copayment for two different inpatient stays. 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 $310 
copayment per day for days 1-5 for inpatient hospital services.  
 
You were in the hospital for 3 days, however the hospital is only going to charge you for 2 days, resulting in a  
$620 total copayment ($310 x 2 = $620). You have been asked to pay a $620 total copayment per day for an in-network inpatient stay. This item/service 
falls within the inpatient hospital services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for an in-network inpatient stay provided from January 6, 2023, to January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953) 
provided on September 7, 2022. 
 
You asked the Plan to pay for bone replacement graft. 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 bone 
replacement graft for ridge preservation (D7953) provided on September 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81405, 81406, 81407, 81408).  
 
You asked the Plan to pre-approve genetic testing. You say that you would like genetic testing due to family 
history. The Plan denied your request. The Plan says there is no documentation submitted that shows you have signs or symptoms of a connective tissue disorder or how the testing will impact your medical treatment or 
management. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is covered when the results of the 
testing directly impact treatment or management 
 
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 genetic testing. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the test will not have an impact on 
your treatment. The requested test is not a diagnostic test. There is no evidence to support its role in your 
clinical management. In summary, the requested testing is not considered reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81405, 81406, 81407, 81408).