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

 
We decided that the Plan does not have to waive the cost for an in-network annual visit with diagnostic tests 
provided on March 20, 2023. 
 
You asked the Plan to waive the cost for an in-network annual visit with diagnostic tests . You say that you've 
had these tests done before and they were covered under your annual visit. You never had to pay anything 
extra. 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 an $800 deductible which applies to "Welcome to Medicare preventive 
visit.  
 
You have been asked to pay $101.11 towards this $800 deductible for 2023. 
 
The item or service you asked the Plan to waive the cost for falls within the "Welcome to Medicare preventive 
visit benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an 
$800 deductible which applies to "Welcome to Medicare preventive visit.  This cost sharing is a contractual obligation that had not been met at the time an in-network annual visit with 
diagnostic tests was received on March 20, 2023. Therefore, we decided that the Plan does not have to waive 
the cost for an in-network annual visit with diagnostic tests provided on March 20, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 27, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the patient was in a nursing home at the 
time the services were rendered. You say that your company has an exclusive contract with this facility and 
your doctors are the only providers who will treat the patients for internal medicine care. The Plan denied your 
request. 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 Plan says that the Plan has also determined 
that these services are not urgent or emergent, nor were they approved in advance.  
 
 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 
services 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 physician's services provided on March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation treatment delivery provided on 
May 15, 2023. 
 
You asked the Plan to waive the coinsurance for radiation treatment delivery. You say that you were not aware 
that you had a coinsurance. 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 therapeutic radiology services. 
 
You have been asked to pay 20% coinsurance for radiation treatment delivery. This item/service falls within 
the therapeutic radiology 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. However, you only owe $42.34 because your out-of-pocket maximum was met 
during the processing of the claim. Therefore, we decided that the Plan does not have to waive the coinsurance 
for radiation treatment delivery provided on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse more for frames (V2020) and bifocal sphere lenses 
(V2200) provided on May 3, 2023.  
 
You asked the Plan to reimburse more for frames (V2020) and bifocal sphere lenses (V2200). You say that you 
are upset that your reimbursement was denied. The Plan denied your request. The Plan says your benefit 
coverage does not allow for multiple pairs of eyeglasses. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $150 when you purchase your glasses from a Plan vision provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that if you purchase glasses outside of the Plan 
vision collection, but at a Plan vision provider, you are covered up to $150. The record shows this benefit has 
been exhausted. Based on this information, we decided that the Plan's rules for coverage of frames (V2020) and 
bifocal sphere lenses (V2200) have not been met. Therefore, we decided that the Plan does not have to 
reimburse more for frames (V2020) and bifocal sphere lenses (V2200) provided on May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - two surfaces, anterior (D2331) 
provided on June 28, 2023. 
 
You asked the Plan to pay for the dental service. You say that you confirmed with the plan that this dentist in in 
your plan and you used the same dentist on March 22, 2023. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the resin-based composite - two surfaces, anterior (D2331) provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 29, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. 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 
services 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 subsequent nursing facility care provided on June 29, 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 August 2, 2022. 
 
You asked the Plan to pay for bone replacement graft for ridge preservation (D7953). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says this is not a covered 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 pay for bone 
replacement graft for ridge preservation (D7953) provided on August 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says the requested device is not covered under Medicare 
rules. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft on tooth #8 (D7953). 
 
You asked the Plan to pre-approve bone replacement graft on tooth #8. You say that the service is necessary. 
The Plan denied your request. The Plan says the requested service is not covered. 
 
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 bone 
replacement graft on tooth #8 (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you take insulin every night before you go to bed. 
You also say that you can't carry your insulin in your backpack whenever you travel to friends or family's home 
for a sleepover. The Plan denied your request. The Plan says the notes do not show that you meet the 
conditions for coverage. The plan also says that it was confirmed with the doctor's office there is no order on 
file and you first need to see your doctor to be evaluated for the CGM. 
 
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 you do not use insulin or have had 
an in-person visit with your treating physician to evaluate your 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 continuous 
glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 25, 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 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 Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 
services 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 on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit (99212). 
 
You asked the Plan to pre-approve a specialist office visit (99212). You say that you received a provider list 
with the Plan, and they all said they do not accept this insurance. The Plan denied your request. The Plan says 
this provider is not part of the Plan network and is not uniquely qualified to treat your diabetes and eye pain. 
 
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 
a specialist office visit (99212).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 16, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says 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 Plan says that the Plan has 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 
services 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 physician's services provided on February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you cannot use the tanks as it 
has been proven in the past. The Plan denied your request. The Plan says that a portable oxygen concentrator is 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
  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 portable oxygen concentrator. Our 
reviewer says that a portable oxygen concentrator is medically necessary. Our physician reviewer found that 
you have chronic hypoxemia and require oxygen therapy but cannot transport your current tank due to weight 
and size. Furthermore, to obtain the benefit from oxygen and be able to continue with activities of daily living, 
you require a portable oxygen concentrator. 
 
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 portable oxygen concentrator have been met. Therefore, we decided that the 
Plan has to pre-approve a portable oxygen concentrator.  
 
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 pre-approve 2 additional implant services (D6057, D6058). 
 
You asked the Plan to pre-approve 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 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 with the Plans approved authorization 
A0230606154081. Therefore, we decided that the Plan does not have to pre-approve 2 additional implant 
services (D6057, D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the intraoral radiographic 
images (D0220 and D0230), bitewings (D0274), and the periodontal maintenance (D4910) provided on August 
5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were denied for a duplicate request, 
but you thought x-rays and maintenance were covered. The Plan denied your request. The Plan says the denial 
of payment for these services is correct, because they are not covered by the Plan or Medicare. 
 
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 periodic oral evaluation 
(D0120), the intraoral radiographic images (D0220 and D0230), bitewings (D0274), and the periodontal 
maintenance (D4910) provided on August 5, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99282, 10061) provided on May 
16, 2023. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes 99282, 10061 are not supported in the medical record. Specifically, the codes were 
billed with the 27 modifier but records show only one evaluation and management service for this date of 
service. The 27 modifier cannot be reported with a surgery code. Based on this information, we decided that 
Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99282, 10061) provided on May 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 A6530 that 
were issued on June 14, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that you wear the stockings for blood clots 
and you have a digital breast tomosynthesis (DBT) filter in your chest. You have been wearing these since 
2001 and the other stockings your have do not work as well as these. The Plan denied your request. The Plan 
says your coverage does not provide for this service.  
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (D4263), the guided tissue regeneration 
(D4266), and the surgical placement of the implant body (D6010) for tooth #9. 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are necessary so you 
can recover to your normal life and to be able to eat well. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because the bone graft, the guided tissue regeneration, and 
dental implants and all associated services 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 a 
bone graft (D4263), the guided tissue regeneration (D4266), and the surgical placement of the implant body 
(D6010) for tooth #9.