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

 
We decided that the Plan does not have to waive the copayments for two in-network office visits, and an out-
of-network duplex scan provided from March 21, 2023, to April 5, 2023. 
 
You asked the Plan to waive the copayments for two in-network office visits, and an out-of-network duplex 
scan. You say that you already paid a $50 copayment for one of these visits, you should not have to pay all this 
extra money. 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 $50 
copayment for specialists' visits and a $75 copayment for out-of-network diagnostic procedures and tests.  
You had two specialists visits ($50 x 2 = $100) and a duplex scan ($100 + $75 = $175) resulting in a $175 
total copayment.  You have been asked to pay a $175 total copayment for two in-network office visits, and an out-of-network 
duplex scan. This item/service falls within the specialists' visits and out-of-network diagnostic procedures and 
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 copayments for two in-network office visits, 
and an out-of-network duplex scan provided from March 21, 2023, to April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on May 18, 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 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 benefit for the requested item or service was exhausted on date of service February 22, 2023, and 
March 1, 2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) 
provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on May 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that this is medically necessary. 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 benefit for the requested item or service was exhausted on date of service April 19, 2023, and May 
3, 2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) provided 
on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a maxillary interim partial 
denture (D5820), an office visit (D9430), a mandibular partial denture (D5214) provided on May 4, 2023, to 
May 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were advised that this provider is in-
network. 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 limited oral evaluation (D0140), a maxillary interim partial denture (D5820), an office visit 
(D9430), a mandibular partial denture (D5214) provided on May 4, 2023, to May 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CGM supplies provided on January 30, 
2023, to June 4, 2023. 
 
You asked the Plan to waive the copayment for the CGM supplies. You say that you were told, by your 
provider, the CGM supplies would be free. 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 a 20% 
coinsurance for each Medicare covered continuous glucose monitor and supplies. 
  You have been asked to pay a total of $1,577.04 for the CGM supplies.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
January 30, 2023 CGM supplies $1,575 20% $315 
March 2, 2023 CGM supplies $1,585.21 20% $317.04 
April 3, 2023 CGM supplies $1,575 20% $315 
May 4, 2023 CGM supplies $1,575 20% $315 
June 4, 2023 CGM supplies $1,575 20% $315 
TOTAL:    $1,577.04 
 
This item/service falls within the diabetes self-management training, diabetic 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 copayment for the CGM supplies provided on January 30, 
2023, to June 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental surgery for removal of teeth. 
 
You asked the Plan to pre-approve the dental services. You say that the requested surgery is medically 
necessary, and you are requesting coverage under Medicare and not the enrollee's supplemental coverage. The 
Plan denied your request. The Plan says the requested dental services are not covered by Medicare and the 
provider can request coverage under the enrollee's supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage when the services are requested under the supplemental benefit. 
 
The requested dental surgery for removal of teeth in dispute meets the Medicare definition of dental, since it is 
a service which involved the care and treatment of teeth or structures directly supporting the teeth. The dental 
surgery for removal of teeth does not fall under any of Medicare exceptions for coverage of non-routine dental 
care. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the 
Plan does not have to pre-approve the dental surgery for removal of teeth.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan provided 
on June 01, 2023. 
 
You asked the Plan to waive the copayment for computed tomography (CT) scan. You say that you do not feel 
you should have to pay for the CT scan. 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 $150 
copayment for Other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays.. 
 
You have been asked to pay a $150 copayment for computed tomography (CT) scan. This item/service falls within the Other outpatient diagnostic tests - Radiological diagnostic services, not including x-rays. 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. However, since 
the allowed amount is less than the standard copayment, you only owe $114.20. Therefore, we decided that the 
Plan does not have to waive the copayment for computed tomography (CT) scan provided on June 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lens (V2781), polycarbonate or equal (V2784), 
variable asphericity lens, bifocal (V2430), antireflective coating (V2750), photochromatic tint (V2744), frames 
(V2020), and vision supplies, accessories (V2797) provided on June 23, 2023. 
 
You asked the Plan to pay for progressive lens (V2781), polycarbonate or equal (V2784), variable asphericity 
lens, bifocal (V2430), antireflective coating (V2750), photochromatic tint (V2744), frames (V2020), and vision 
supplies, accessories (V2797). You say that you were never told there would be an added fee for this service. 
The Plan denied your request. The Plan says this benefit has been exhausted. 
 
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 a $200 benefit 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 they off a $200 benefit toward the purchase and 
fitting of eyeglasses and pair of lenses. The record shows that this benefit was exhausted with this date of 
service. Based on this information, we decided that the Plan's rules for coverage of progressive lens (V2781), 
polycarbonate or equal (V2784), variable asphericity lens, bifocal (V2430), antireflective coating (V2750), 
photochromatic tint (V2744), frames (V2020), and vision supplies, accessories (V2797) have not been met. 
Therefore, we decided that the Plan does not have to pay for progressive lens (V2781), polycarbonate or equal 
(V2784), variable asphericity lens, bifocal (V2430), antireflective coating (V2750), photochromatic tint 
(V2744), frames (V2020), and vision supplies, accessories (V2797) provided on June 23, 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), and prophylaxis - adult 
(D1110) provided on June 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told by the website, a plan 
representative and the provider that they were in-network. 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 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), and prophylaxis - adult (D1110) provided on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported to denture (D6111), a semi-
precision abutment (D6191) for tooth #22 and #27, and a semi-precision attachment (D6192) for tooth #22 and 
#27. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for the placement 
of 2 implants on the lower arch for the enrollee. The Plan denied your request. The Plan says the denial of 
authorization for these services is correct, because the implant supported to denture, a semi-precision abutment, 
and a semi-precision attachment 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 pre-approve an 
implant supported to denture (D6111), a semi-precision abutment (D6191) for tooth #22 and #27, and a semi-
precision attachment (D6192) for tooth #22 and #27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that this is medically necessary. 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 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 28, 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 $1,250 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 dental services provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the stem cell injections of the left knee 
(99199) provided on January 4, 2023. 
 
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 this service is not a covered 
benefit.  
 
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 issue reimbursement for the stem cell injections of the left knee (99199) provided on 
January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not covered when prescribed by an 
out-of-network provider.  
 
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 prescribed by a network provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when prescribed by a network provider. However, the hearing aids in this case were requested to be 
prescribed by an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve 
hearing aids to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lens fitting (92310) provided on June 23, 2023.  
You asked the Plan to pay for contact lens fitting (92310). You say that contact lens evaluation is part of the 
contact lenses eye examination. 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 these services when . 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $300 benefit toward the purchase of 
contact lenses. Contact lens fitting is excluded from this benefit. Based on this information, we decided that the 
Plan's rules for coverage of contact lens fitting (92310) have not been met. Therefore, we decided that the Plan 
does not have to pay for contact lens fitting (92310) provided on June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation (D9310) and a cone beam CT (D0364) provided 
on May 8, 2023. 
 
You asked the Plan to pay for consultation and a cone beam CT. You say that this should be covered. The Plan 
denied your request. The Plan says these are not covered services. 
 
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 
consultation (D9310) and a cone beam CT (D0364) provided on May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary overdenture (D5863). 
 
You asked the Plan to pre-approve D5863. You say that you need this dental work. The Plan denied your 
request. The Plan says the requested dental service is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete maxillary overdenture (D5863).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower 
denture (D5120) provided on November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because 
dentures 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 
complete upper denture (D5110) and a complete lower denture (D5120) provided on November 3, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the ultrasound guidance for vascular access requiring ultrasound 
evaluation of potential access sites (76937) provided September 21, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that the primary procedure code of 76937 for date of service September 21, 2022, has not been 
paid; therefore, the add-on code of 76937 is not payable. 
 
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. Review of the file does not show that the Plan's denial is substantiated.  
Therefore, we decided that the Plan has to pay for the ultrasound guidance for vascular access requiring 
ultrasound evaluation of potential access sites (76937) provided September 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the enrollee underwent 
an epidural steroid injection on August 23, 2023, and was seen again on September 26, 2023, with 50 % pain 
improvement. However, the LCD criteria requires 50% pain relief for three months which has not yet passed. 
Therefore, the request is not medically reasonable and 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.