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

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures in a move last year 
and have been unable to find them. 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 13, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5225).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000).  
 
You asked the Plan to pre-approve foot orthotics. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says this item is not a covered benefit. The 
record does not indicate that the enrollee meets the clinical requirements for them to be approved. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics (L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve freestyle lite blood glucose test strips. 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that the items should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says only the preferred brand 
products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve freestyle lite 
blood glucose test strips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an injection and specialist visit provided on 
February 17, 2023. 
 
You asked the Plan to reduce the cost share for an injection and specialist visit. You say that you were not 
expecting to have a $600 copayment for the service rendered. 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 intravenous, subcutaneous, and biological Part B drugs and a $30 copayment for a specialist 
visit.  
 
You have been asked to pay $605.04 for an injection and specialist visit. This total includes $575.04, which is 
20% of the allowed amount for a Medicare Part B injection drug ($2,875.20 allowed x 20% = $575.04) and a 
$30 copayment for a specialist visit. The injection falls within the Medicare Part B prescription drugs benefit 
category. The specialist visit falls within the physician/practitioner 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 reduce the cost share for an injection and specialist visit provided on February 17, 2023.
Appeal type: Supplemental Benefit
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 are asking for the Plan to cover an 
additional 49 miles for a total of 99 miles. The Plan denied your request. The Plan says the additional mileage 
beyond the allowed 50 miles is not covered. 
 
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 50 miles one-way per trip.  
 
We looked at your request, the records in the case file, and the rules. You are requesting a trip of 99 miles. 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on January 3, 2023. 
 
You asked the Plan to pay for the core buildup, including any pins when required. You say that the core 
buildup on tooth #13 was required to prepare the tooth for a crown. The Plan denied your request. The Plan 
says there is no coverage for D2950-core buildup, including any pins when required. 
 
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 core 
buildup, including any pins when required (D2950) provided on January 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on February 5, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the correct 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. The Z-code on the claim is not listed as valid for the CPT code billed. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for lab services (81479) provided on February 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tetanus-diphtheria and Shingles vaccines provided on April 
13, 2023. 
 
You asked the Plan to pay for tetanus-diphtheria and Shingles vaccines. You say that it is medically necessary. 
The Plan denied your request. The Plan says per Medicare rules, some vaccines such as Shingles and tetanus-
diphtheria vaccines are covered by Medicare Part D.  
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide tetanus-diphtheria 
and shingles vaccines. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to tetanus-diphtheria 
and shingles vaccines. Therefore, we decided that the Plan does not have to pay for tetanus-diphtheria and 
Shingles vaccines provided on April 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 9, 2023, 
to February 23, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the copayment 
assessed for the SNF stay. 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 $0 
copayment for days 1 to 20 and a $196 copayment each day for days 21 to 100 for SNF care.  
 You have been asked to pay $1,196.52 for a SNF stay. This total is less than the standard copayment for a SNF 
stay because your maximum out-of-pocket was met during the processing of this claim. This item/service falls 
within the SNF care 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 a SNF stay provided 
from January 9, 2023, to February 23, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for rehabilitation services provided from January 3, 
2022, to December 30, 2022. 
 
You asked the Plan to waive the cost for rehabilitation services. You say that the cost share should be covered 
as the Plan is the enrollee's secondary insurance. 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. Your 
contract with the Plan says that there is $500 deductible which applies to outpatient rehabilitation services and 
a $5 copayment for physical, speech, and occupational therapy visits, after the deductible is met.  
 
 The item or service you asked the Plan to waive the cost for falls within the outpatient rehabilitation services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 
deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that 
had not been met at the time rehabilitation services was received on January 3, 2022, to December 30, 2022. 
Therefore, we decided that the Plan does not have to waive the cost for rehabilitation services provided from 
January 3, 2022, to December 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 31, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you thought 
the authorization was approved but found out it was denied after taking the test. 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 $225 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $225 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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 $97.23, which is less than the standard amount for a CT 
scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography 
(CT) scan provided on March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided from March 2, 2023, to 
March 15, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers 
require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided from March 2, 2023, to  
March 15, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for rehabilitation services provided from January 2, 
2023, to February 6, 2023. 
 
You asked the Plan to waive the cost for rehabilitation services. You say that the cost share should be covered 
as the Plan is the enrollee's secondary insurance.  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. Your 
contract with the Plan says that there is $400 deductible which applies to outpatient rehabilitation services and 
a $5 copayment for physical, speech, and occupational therapy visits, after the deductible is met.  
 
 
  The item or service you asked the Plan to waive the cost for falls within the outpatient rehabilitation services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $400 
deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that 
had not been met at the time rehabilitation services was received on January 2, 2023, to February 6, 2023. 
Therefore, we decided that the Plan does not have to waive the cost for rehabilitation services provided from 
January 2, 2023, to February 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on November 6, 2022 to 
December 1, 2022. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 6, 2022. The NOA was not received by the Plan until January 
25, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on November 6, 2022 to December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit and a determination 
of refractive state provided on May 23, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit and a determination of refractive state. 
You say that the examination should have been under the allotted examination within your Medicare policy. 
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 Medicare-covered examination to diagnose and treat diseases or conditions of the eye. 
 
You have been asked to pay a $45 copayment for a specialist office visit and a determination of refractive state. 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. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit and 
a determination of refractive state provided on May 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van transportation (A0130) provided on January 
18, 2023. 
 
You asked the Plan to pay for the wheelchair van transportation. You say that you were in no frame of mind to 
request a specific type of ambulance and the company should be experienced enough to know a Medicare 
recipient cannot use a wheelchair van. The Plan denied your request. The Plan says wheelchair van (chair car) 
transportation is not covered by Medicare even if provided by an ambulance company. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for wheelchair van transportation (A0130) provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on March 23, 2023. 
 
You asked the Plan to pay for core buildup, including any pins when required (D2950). You say that the tooth 
was structurally damaged badly and a core build up was required to reinforce the tooth that will last many 
years. The Plan denied your request. The Plan says according to your EOC there is no coverage for core 
buildup, including any pins when required. The Plan also says that the records indicate you did not contact the 
Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 core 
buildup, including any pins when required (D2950) provided on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete upper denture (D5110) and the complete 
lower denture (D5120) provided on September 12, 2022. 
 
You asked the Plan to pay more for the dental items. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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. Additionally, the annual maximum allowable dental benefit per year is $1,000. 
 
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. 
 
  
 
 
 
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.  
Additionally, the Plans contract states that the maximum allowable dental benefit per year is $1,000. The Plan 
issued payment in the amount of $1,000 for dental items/services provided to you this calendar year. Therefore, 
you have exhausted the allowable benefit for the dental items provided in this case. Therefore, we decided that 
the Plan does not have to pay more for the complete upper denture (D5110) and the complete lower denture 
(D5120) provided on September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6210) provided on March 18, 2023. 
 
You asked the Plan to pay for a pontic. 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 a pontic 
(D6210) provided on March 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 27, 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 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 March 27, 2023.