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

 
We decided that the Plan does not have to pay more for a crown (D2751) for tooth #10 provided by an out-of-
network provider on November 12, 2022. 
  You asked the Plan to pay more for the dental service. You say that you did not receive a porcelain crown and 
you do not understand the bill. 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. Also, the proper cost share was applied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The total amount billed for the crown was $1,200 and the total allowed amount was $771 leaving a difference 
of $429 ($1,200 billed - $771 allowed). The total allowed amount was $771 with a coinsurance of $385.50 
($771 allowed x 50% coinsurance). The total enrollee responsibility for the crown was $814.50 ($429 
difference + $385.50 coinsurance). You have been asked to pay the difference between the out-of-network 
providers charges and the Plans payment along with the coinsurance amount. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan 
does not have to pay more for a crown (D2751) for tooth #10 provided by an out-of-network provider on 
November 12, 2022.  
 
Your complaint about your experience and what the out-of-network provider billed 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0427) and 
ground mileage (A0425) provided on September 14, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that you 
would like this claim to be reviewed and reprocessed for payment, as this is a result of the enrollee not 
providing the insurance in a timely manner. The Plan denied your request. The Plan says Medicare denies a 
claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the 
date the services were furnished. The Plan also says this claim was received on February 2, 2023, which is past 
the allowed 12-month timeframe. 
 
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 emergency ambulance transportation and ground mileage was not filed 
until February 2, 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 the emergency ambulance 
transportation (A0427) and ground mileage (A0425) provided on September 14, 2021.
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 are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
specifically the medical records provided state that the enrollee has pre-diabetes. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you didn't know the provider was out of 
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 dental services provided on January 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralight wheelchair (K0005) and accessories. 
 
You asked the Plan to pre-approve an ultralight wheelchair and accessories. You say that the requested 
wheelchair is medically necessary. The Plan denied your request. The Plan says the requested wheelchair is not 
necessary to meet the enrollee's needs. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
The records show that an ultralight wheelchair and accessories are being requested for use in a SNF or hospital.  
Therefore, we decided that the Plan does not have to pre-approve an ultralight wheelchair (K0005) and 
accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2. 
 
You asked the Plan to pre-approve the Freestyle Libre 2. The Plan denied your request. The Plan says the 
enrollee does not have documentation of history of problematic hypoglycemia. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a history 
of problematic hypoglycemia.  Based on this information, we decided that Medicare rules for coverage of the 
Freestyle Libre 2 have not been met.  Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visits provided on August 
2nd, 2022, to January 25, 2023. 
 
You asked the Plan to waive the copayment for each telehealth visit. You say that you are disputing the share 
cost. 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 $40 
copayment for Outpatient mental health care.  
 
You have been asked to pay $40 copayment for each telehealth visit. This item/service falls within the 
Outpatient mental health 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 the 
telehealth visits provided on August 2nd, 2022, to January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional chiropractic manipulative treatments 
(98941). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 these services. Our reviewer says that 
the requested services are not medically necessary. Our physician reviewer found that in this case, the record 
indicates that the enrollee has a cervical and lumbar subluxation. The records of these visits do not establish 
that clinical improvement can be reasonably expected from ongoing care. The record provided does not support 
progressive improvement of symptoms but rather maintenance therapy.   
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested services. The elements of the coverage criteria are not satisfied. The requested services are not 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 3 additional chiropractic manipulative treatments (98941).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant 
(D6010) provided on December 6, 2022. 
 
You asked the Plan to pay for the surgical placement of implant body. You say that you have been in pain for 
the past year and due to bone deterioration, you had no other options to properly seat your denture. The Plan 
denied your request. The Plan says this service is not covered under the benefit package. 
 
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 surgical 
placement of implant body: endosteal implant (D6010) provided on December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required for 
tooth number 25 (D2950). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this item 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 item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup, 
including any pins when required for tooth number 25 (D2950).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 12, 2022, billed with 
codes 81314, 81345, 81218, 81209 and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported as billed. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 12, 2022, billed with codes 81314, 81345, 81218, 81209 and 81272.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the walking boot provided on January 3, 
2023. 
 
You asked the Plan to waive the deductible for walking boot. You say that you are disputing the share cost. 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 $220.82 
deductible for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay $220.82 deductible for the walking boot. This item/service falls within the Durable 
medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
deductible for the walking boot provided on January 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of x-ray 
images and maxillary complete denture provided on December 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you never received the denture. 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 comprehensive oral evaluation, complete series of x-ray images and maxillary complete denture 
provided on December 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Brain imaging, positron emission tomography (PET); 
metabolic evaluation (78608). 
 
You asked the Plan to pre-approve positron emission tomography. You say that the enrollee is having memory 
loss for 6 months and is getting progressively worse.  The Plan denied your request. The Plan says the records 
do not indicate the enrollee meets the diagnostic criteria of both Alzheimer's and frontotemporal dementia. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 positron emission tomography. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found in this case the enrollee 
is noted to have a cognitive impairment/dementia. The records provided did not support that the member met 
diagnostic criteria. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of positron emission tomography have not been met.  Therefore, we decided that 
the Plan does not have to pre-approve a Brain imaging, positron emission tomography (PET); metabolic 
evaluation (78608).
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 you would like to request reconsideration of 
the denied authorization. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visual acuity screening (99173) provided December 15, 
2022. 
 
You asked the Plan to pay for the screening test. You say that you assumed that this was a part of your annual 
wellness exam, as that exam was the only reason for your visit that day. You feel you should have been notified 
prior to the vision test that it would not be covered.  The Plan denied your request. The Plan says the criteria for 
coverage has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99173 is screening test of visual acuity, quantitative, 
bilateral. 
 
We find that CPT code 99173 is not supported in the medical record. Specifically, this procedure as billed with 
the GY modifier, indicating that 9173 is not eligible for payment. This code also has a status indicator of N or Not covered. Based on this information, we decided that Medicare rules for coverage of the screening test have 
not been met. Therefore, we decided that the Plan does not have to pay for the visual acuity screening (99173) 
provided December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hearing exam provided on February 06, 
2023. 
 
You asked the Plan to waive the copayment for a hearing exam. You say that you are disputing the share cost. 
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 $15 
copayment for Hearing services. 
 
You have been asked to pay a $15 copayment for a hearing exam. This item/service falls within the Hearing 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a hearing exam provided 
on February 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on December 15, 
2022. 
 
You asked the Plan to pay for an office visit and related services. You say that the services should be covered. 
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 and 
related services provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2710 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that your teeth are giving you a headache and 
you need these services. The Plan denied your request. The Plan says this service is not a covered benefit under 
your dental 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 
crowns (D2710 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - three surfaces, posterior (D2393) 
provided on January 10, 2023. 
 
You asked the Plan to pay for the resin-based composite - three surfaces, posterior. You say that you do not 
understand why a filling would not be covered.  The Plan denied your request. The Plan says this service is not 
covered under the benefit package. The Plan also confirmed with your dental office that you signed a consent 
form and scheduled a January appointment. Your dentist charged you the contracted fee of $198 as a courtesy 
instead of $285. 
 
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 resin-
based composite - three surfaces, posterior (D2393) provided on January 10, 2023.