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

 
We decided that the Plan does not have to pay for the immediate denture - mandibular (D5140) provided on 
July 28, 2023. 
 
You asked the Plan to pay for the denture. You say that in 2019 you had a lower partial done but the 8 teeth 
that were extracted had to be pulled. You also say that you have no lower teeth to eat with and are not in a 
position to pay for the denture. The Plan denied your request. The Plan says your benefit for the denture 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 service was exhausted on date of service January 18, 2019. Therefore, we 
decided that the Plan does not have to pay for the immediate denture - mandibular (D5140) provided on July 
28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on April 24, 2023. 
 
You asked the Plan to pay for the vision services. You say that you are requesting reconsideration of the denied 
claim. 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 the vision services 
provided on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120), surgical 
removal of an implant body (D6100), guided tissue regeneration, of natural teeth-resorbable barrier, per site 
(D4266), a bone replacement graft for ridge preservation-per site (D7953), and therapeutic parenteral drugs, 
two or more administrations, of different medications (D9612). 
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says the requested items/services are not covered 
under the supplemental dental policy.  
 
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/services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
fixed partial denture sectioning (D9120), surgical removal of an implant body (D6100), guided tissue 
regeneration, of natural teeth-resorbable barrier, per site (D4266), a bone replacement graft for ridge 
preservation-per site (D7953), and therapeutic parenteral drugs, two or more administrations, of different 
medications (D9612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for catheters provided on June 08, 2023. 
 
You asked the Plan to waive the coinsurance for catheters. You say that you want to appeal the amount being 
charged. 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 prosthetic devices and related supplies. 
 
You have been asked to pay 20% coinsurance for catheters. This item/service falls within the prosthetic devices 
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. The total you owe is $156.17 ($780.84 allowed amount x 20% = $156.17). Therefore, we decided 
that the Plan does not have to waive the coinsurance for catheters provided on June 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care management services provided on June 30, 2023, by 
an OON provider.  
 
You asked the Plan to pay for the care management services. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the care management services provided on June 
30, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete mandibular denture (D5120) provided on August 
2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have had issues with the temporary 
dentures. You also say you are not able to eat and have to add huge globs of glue in order to have them fit 
properly. The Plan denied your request. The Plan says your benefit for the requested item or service or related 
code 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 November 28, 2022. 
Therefore, we decided that the Plan does not have to pay for a complete mandibular denture (D5120) provided 
on August 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 and supplies. 
 
You asked the Plan to pre-approve the Dexcom G6 and supplies. The Plan denied your request. The Plan says 
no clinical rationale was provided for why you need a non-preferred CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that that plans may limit coverage to certain brands of 
products and that the plan only covers Freestyle Libre CGMs. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Dexcom G6 and supplies  have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dexcom G6 and supplies.
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 
(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 the requested item is not covered under the 
supplemental dental policy.  
 
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 (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the dental services provided on November 7, 
2022. 
 
You asked the Plan to reimburse you for the dental services. You say that you are asking to reconsider the 2022 
submitted receipts for reimbursement. The Plan denied your request. The Plan says the last day to submit 
receipts for reimbursement for the calendar year 2022 was March 31, 2023. 
 
Medicare generally does not cover dental services. However, the Plan offers a supplemental benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a Pick You Perks Reimbursement benefit in excess of Medicare coverage, certain rules 
and conditions must be met in order to use this benefit. The Plan requires that all claims for a previous calendar 
year must be submitted no later than March 31
st
 of the following  year. Therefore, we decided that the Plan 
does not have to reimburse you for the dental services provided on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 21, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. 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 the office visit provided 
on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and the therapeutic procedure provided on 
June 27, 2023. 
 
You asked the Plan to pay for an office visit and the therapeutic procedure. You say that you are requesting 
reconsideration of the denied claim. 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 the 
therapeutic procedure provided on June 27, 2023.
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 June 20, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you feel you 
should not be charged an additional copayment for a CT scan. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $270 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $270 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
computed tomography (CT) scan provided on June 20, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on July 24, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you are requesting reconsideration of the denied 
claim. 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 physical therapy 
provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
April 6, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the lower and sacral spine provided by a 
chiropractor on July 10, 2023. 
 
You asked the Plan to pay for the x-ray exam of the lower and sacral spine. You say that you feel scammed. 
The Plan denied your request. The Plan says 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 pay for the x-ray exam of the lower and sacral spine provided by a chiropractor on 
July 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (T1021). 
 
You asked the Plan to pre-approve the home health services. You say that the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
custodial care is excluded from Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home 
health services (T1021).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on May 31, 
2023, to June 28, 2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you were told there would be no 
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 $360 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $360 copayment for physical therapy. 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. You have been asked to pay a total of $360 for physical therapy visits ($30 x 12 
visits = $360). Therefore, we decided that the Plan does not have to waive the copayment for physical therapy 
provided on May 31, 2023, to June 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 17, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261), accessory charger 
(V5267), and the comprehensive audiometry evaluation (92557) purchased on March 15, 2022. 
 
You asked the Plan to issue reimbursement for these items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the 
items/services at issue are not payable as the claim was submitted untimely.  
 
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 these items/services was not filed until June 7, 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 issue reimbursement for the hearing aids (V5261), accessory charger (V5267), and 
the comprehensive audiometry evaluation (92557) purchased on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant/abutment supported fixed denture (D6114) 
provided on May 26, 2022. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this dental item is not a covered benefit.  
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The dental item you are asking the Plan to pay for involves the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. This dental item is not covered or paid for by 
Medicare. Therefore, we decided that the Plan does not have to pay for the implant/abutment supported fixed 
denture (D6114) provided on May 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on January 27, 
2023. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you were told the copayment 
was $5. 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 $20 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for physical therapy. 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. Therefore, we decided that the Plan does not have to waive the copayment for physical 
therapy provided on January 27, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 17, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. 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 psychotherapy provided 
on April 17, 2023.