Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each occupational therapy (OT) visit 
provided on April 17, 2023, to May 01, 2023. 
 
You asked the Plan to reduce the copayment for each occupational therapy (OT) visit. You say that you were 
advised there would only be a $5 copayment. 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 $25 
copayment for outpatient rehabilitation services.  
You have been asked to pay a $25 copayment for each occupational therapy (OT) visit. This item/service falls 
within the outpatient rehabilitation 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. The total copayment you owe is $75 for OT services ($25 per visit x 3 visits 
= $75). Therefore, we decided that the Plan does not have to reduce the copayment for each occupational 
therapy (OT) visit provided on April 17, 2023, to May 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee requires a non-invasive 
ventilation system instead of a BiPAP because they have a ventilatory disorder and a BiPAP could increase 
their work of breathing. The Plan denied your request. The Plan says a home ventilator is not medically 
necessary for this patient because their needs can be met with an alternative device such as a BiPAP device 
with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that there is no 
documented evidence that a home ventilator is required. Also, there is no supporting data or study to indicate 
the need for a home ventilator. Therefore, the patient does not meet the standard of care for a home ventilator, 
given the documentation provided. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 21, 2012. 
 
You asked the Plan to pay for the home health services. You say that the claim was submitted in time, and it 
needs to be reprocessed as corrected claims. The Plan denied your request. The Plan says the time limit for 
filing of the claims has expired. 
 
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 home health services was not filed until April 6, 2023. 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 home health services provided on March 21, 2012.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manual therapy techniques and electrical stimulation 
provided by a chiropractor on May 15, 2023. 
 
You asked the Plan to pre-approve manual therapy techniques and electrical stimulation. You say that a regular 
physician cannot provide you the treatment you need because you do not believe a popped rib is a thing that 
occurs. The Plan denied your request. The Plan says that the only covered chiropractic service is manual 
manipulation of the spine. 
 
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 pre-approve manual therapy techniques and electrical stimulation provided by a 
chiropractor on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210) provided on May 16, 2023. 
 
You asked the Plan to pay more for the dental services. You say that according to your medical and dental 
benefits, the exact procedure that was done is covered with zero coinsurance. You also say that this procedure 
does not apply to the deductible. 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. 
 
 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 an extraction of an erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210) provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, vision testing, diagnostic imaging and 
reading, and other vision services provided on November 16, 2022. 
 
You asked the Plan to pay for an office visit, vision testing, diagnostic imaging and reading, and other vision 
services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
that unauthorized, out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit, vision 
testing, diagnostic imaging and reading, and other vision services provided on November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction and bone replacement graft (D7140, D7953) 
provided on March 9, 2023, by an out-of-network (OON) provider. 
 
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 an extraction and bone replacement graft (D7140, D7953) provided on March 9, 2023, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) for teeth numbers 4 and 21 and a 
porcelain fused to high noble metal crown (D2750) for teeth numbers 4 and 21. 
 
You asked the Plan to pre-approve core buildup (D2950) for teeth numbers 4 and 21 and a porcelain fused to 
high noble metal crown (D2750) for teeth numbers 4 and 21. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this service is not covered in your 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 core 
buildup (D2950) for teeth numbers 4 and 21 and a porcelain fused to high noble metal crown (D2750) for teeth 
numbers 4 and 21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6750) for teeth numbers 12, 14 and a 
pontic - porcelain fused to high noble metal (D6240) for tooth number 13. 
 
You asked the Plan to pre-approve the dental services. You say that although you had authorization for another 
provider, the work was not done, so I have the benefit available. You also say that you want it approved as 
soon as possible. The Plan denied your request. The Plan says your authorization 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 authorization for the requested item or service was exhausted on date of service February 7, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6750) for teeth numbers 
12, 14 and a pontic - porcelain fused to high noble metal (D6240) for tooth number 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor 
 
You asked the Plan to pre-approve the Dexcom G7 sensor. You say that you are appealing the denied CGM. 
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 a CGM. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 sensor
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that the enrollee needs the shower chair to maintain 
balance and to help them from falling. The Plan denied your request. The Plan says this item is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips for very 
important appointments. The Plan denied your request. The Plan says routine transportation benefits beyond 
the 100 allotted one-way trips are not covered under your plan. 
 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 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional trips for your very important appointments. 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 trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the prophylaxis - adult (D1110) provided on June 26, 
2023. We also decided that the Plan does not have to pay for sales tax (D9985) provided on June 26, 2023. 
 
You asked the Plan to pay more for the prophylaxis. You also asked the Plan to pay for the sales tax. You say 
that you are appealing and are asking the plan to pay the full amount of the dental bill. You also say that the 
charges are reasonable. 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. The Plan also says service D9985 is not covered under your contract under any normal 
circumstances. 
 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 sales tax is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for sales tax (D9985) 
provided on June 26, 2023. 
 
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 the prophylaxis - adult (D1110) provided on 
June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the requested compression 
stockings are medically necessary for the enrollee. The Plan denied your request. The Plan says the item is a 
non-covered item. 
 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 pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimbursement for hearing aids (V5298) provided on March 16, 
2022. 
 
You asked the Plan to reimbursement for hearing aids (V5298). You say that the hearing aids should be 
reimbursed as the enrollee had the benefit of hearing aids available during this time. The Plan denied your 
request. The Plan says there is no coverage for hearing aids when received from a provider other than a Plan 
hearing 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 the hearing aids are obtained through an in-network hearing network provider.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5298) have not been met. Therefore, we decided that the Plan does not have to 
reimbursement for hearing aids (V5298) provided on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator and an oxygen 
concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator and an oxygen concentrator. You say that 
you need the portable oxygen equipment machine so that you can go outside and drive. You say that you have a 
difficult time getting your current equipment into your car. The Plan denied your request. The Plan says the 
requested oxygen equipment is not medically necessary. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator and an oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on April 
25, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that you did not pay for the 
determination of refractive state (92015). The Plan denied your request. The Plan says a determination of 
refractive state (92015) is a non-covered service. 
 
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 does not cover eye refractions. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover outpatient physician services for the 
diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular 
degeneration. Eye refractions are excluded from this benefit. Based on this information, we decided that the 
Plan's rules for coverage of a determination of refractive state (92015) have not been met. Therefore, we 
decided that the Plan does not have to pay for a determination of refractive state (92015) provided on April 25, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second stage implant surgery (D6011), a fabricated 
abutment (D6057), and an abutment supported to crown (D6058) for tooth #24. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because implants and any related 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 
second stage implant surgery (D6011), a fabricated abutment (D6057), and an abutment supported to crown 
(D6058) for tooth #24.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
30, 2023. 
 
You asked the Plan to pay for the dental service. You say that the previous dentist refused to treat you you had 
to find another dentist and for that dentist to treat you an evaluation was needed. 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 the Plan paid for a comprehensive oral evaluation (D0150) on February 10, 2023; therefore, your benefit 
for the requested item or service was exhausted on the date of service of February 10, 2023. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 30, 
2023.  
 
Your complaint about the in-network provider billing for a service is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that the enrollee is treated with cerebrovascular 
accident (CVA), chronic wound care and lung cancer. The enrollee requires transportation to the primary care 
physician, cancer treatment and wound care. The Plan denied your request. The Plan says the enrollee has 
already exhausted their benefit. 
 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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional trips for medical care appointments. 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 trips (A0100).