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

 
We decided that the Plan does not have to pay for an office visit provided on May 03, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the 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 provided 
on May 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260). 
 
You asked the Plan to pre-approve osseous surgery. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
osseous surgery (D4260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Verio strips, lancets and a blood glucose 
monitor. 
 
You asked the Plan to pre-approve the OneTouch Verio strips, lancets and blood glucose monitor. You say that 
the enrollee needs a glucose meter. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested product.  
 The Plan also says criteria must be met:  1. have tried and failed the preferred glucose test strip/disk product 
that is covered by plan, and 2. have prescriber rationale that preferred glucose test strip/disk product cannot be 
used for medical reasons. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to certain brands of 
products and that the plan only covers supplies from Ascensia, and a  blood glucose monitor is limited to the 
Dexcom G5 or G6. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the OneTouch Verio strips, lancets and blood glucose monitor  have not been met. Therefore, we 
decided that the Plan does not have to pre-approve OneTouch Verio strips, lancets and a blood glucose 
monitor.
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 your 
appointments. You also say that you called 2 months ago to request more rides so you would not miss your 
appointments. The Plan denied your request. The Plan says routine transportation benefits beyond the 100 
allotted one-way trips are not covered under the 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 routine transportation trips for your 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional routine transportation trip. 
 
You asked the Plan to pre-approve the additional transportation trip. You say that the services are medically 
necessary. The Plan denied your request. The Plan says with your scheduled trips and what you have already 
used, the requested trip would exceed your yearly limit. 
 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. 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 an additional routine transportation trip.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that the requested MRI is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the denial of authorization for the MRI is correct, 
because the clinical notes do not indicate any neck pain. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that the enrollee 
presented with cites low back pain with issues with walking and balancing due to the low back pain. The exam 
reveals intact strength, reflexes, and sensation. However, detailed documentation regarding a trial and failure of 
recent, reasonable, comprehensive, less invasive conservative care measures is not evident.  
 
  The documentation of conservative treatment is not clearly provided for the cervical spine or the lumbar spine. 
Moreover, there are no cervical spine complaints on the recent exam and the objective findings did not 
corroborate any neurological deficits. The rationale for the requested imaging study is not evident. No 
compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the cervical spine.
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. The Plan denied your request. The Plan says criteria 
for the CGM has not been met and coverage cannot be authorized at this time. 
 
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 use insulin or 
have a history of problematic hypoglycemia, had an in-person visit with their treating physician to evaluate 
their 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 Dexcom G7 sensor have not been met. 
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 pneumatic compressor and segmental pneumatic 
appliance for use with pneumatic compressor to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve pneumatic compressor and segmental pneumatic appliance for use with 
pneumatic compressor. You say that the supplies should be covered. The Plan denied your request. The Plan 
says this is available in-network. 
 
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 
pneumatic compressor and segmental pneumatic appliance for use with pneumatic compressor to be provided 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on April 28, 2022, to 
May 12, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting a reimbursement for 
the cost share paid in advance for skilled nursing facility services received. 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 skilled nursing facility 
care provided on April 28, 2022, to May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 25, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this service is supported in the 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 laboratory services 
provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants for teeth #s 19, 22, 27 and 30 (D6010), bone 
grafts for teeth #s 19, 22, 27 and 30 (D6104), and guided tissue regeneration for teeth #s 19, 22, 27 and 30 
(D6106). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says these are not covered services. 
 
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 implants for teeth #s 19, 22, 27 and 30 (D6010), bone grafts for teeth #s 19, 22, 27 and 30 (D6104), and 
guided tissue regeneration for teeth #s 19, 22, 27 and 30 (D6106).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional transportation services. 
 
You asked the Plan to pre-approve the additional transportation services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says you have exceeded your yearly maximum 
allowance. 
 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 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 the additional transportation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit provided on May 16, 2023. 
 
You asked the Plan to waive the cost share for an office visit. You say that you have not paid this much for this 
service in the past. 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 a $800 deductible which applies to doctor and other health care 
provider services. Your contract with the Plan clearly says that you must pay 10% of the approved amount.  
 
 You have been asked to pay $32.75, which is 10% coinsurance of the allowed amount for the office visit 
($327.51 allowed amount x 10% = $32.75). This item/service falls within the doctor and other health care 
provider 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 also been asked to pay $127.25 towards your $800 deductible. The total amount you owe is $160 
($32.75 coinsurance + $127.25 deductible = $160).The service you asked the Plan to waive the cost share for 
falls within the doctor and other health care provider services benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $800 deductible which applies to doctor and other 
health care provider services. This cost sharing is a contractual obligation that had not been met at the time an 
office visit was received on May 16, 2023. Therefore, we decided that the Plan does not have to waive the cost 
share for an office visit provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health care office visit provided on April 6, 2023, 
by an OON provider.  
 You asked the Plan to pay for the mental health care office visit. You say that there was a delay in receiving 
information about the enrollee's coverage. The Plan denied your request. The Plan says the services were 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 mental health care office visit provided on 
April 6, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - three surfaces, posterior 
(D2393), core buildup, including any pins when required (D2950), and crown - porcelain/ceramic (D2740) 
provided on May 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that apparently your dentist wasnt contracted with 
you at the time of service. You also say that you were unaware of this fact and would have postponed the 
provider if you had known this in advance. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, core buildup is not among those 
covered under this benefit. 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 
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 - three surfaces, posterior (D2393), 
core buildup, including any pins when required (D2950), and crown - porcelain/ceramic (D2740) provided on 
May 15, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for PT services provided on March 21, 2023. 
 
You asked the Plan to reduce the cost share for PT services. You say that the Plan paid nothing towards the 
claim and the enrollee is only responsible for a $25 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. The 
enrollees contract with the Plan says that there is a $500 deductible which applies to outpatient rehabilitation 
services.  The item or service you asked the Plan to reduce the cost share falls within the outpatient rehabilitation services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that 
had not been met at the time PT services was received on March 21, 2023. Therefore, we decided that the Plan 
does not have to reduce the cost share for PT services provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care planning provided on April 12, 2023. 
 
You asked the Plan to pay for the care planning. You say that the enrollee was residing in an assisted living 
facility when services were provided. 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 care planning 
provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for  dental services provided on June 29, 
2023. 
 
You asked the Plan to waive the coinsurance for  dental services. You say that this should be covered in full. 
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 50% 
coinsurance for Class 2 Basic Services.  
 
You have been asked to pay 50% coinsurance and the remainder of the deductible for the dental services. This 
item/service falls within the Class 2 Basic 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 
coinsurance for  dental services provided on June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on March 6, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the drug testing. You say that authorization is not required. The Plan denied your 
request. The Plan says enrollees must receive their care from a network provider. 
 
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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the drug testing provided on March 6, 2023, by an out-of-
network (OON) provider.