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

 
We decided that the Plan does not have to pay the full amount for the porcelain crown (D2740) provided on 
September 13, 2023. 
 
You asked the Plan to pay the full amount for the dental service. You say that you cracked a crown and needed 
it replaced. You say that this was your first claim of the year. You also say that you do not understand how 
your benefit could have been exhausted. The Plan denied your request. The Plan says the annual maximum 
benefit 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 annual maximum dental benefit was exhausted in processing the claim for the date of service in 
this case. The record shows that the Plan paid $917.60 for services provided on September 15, 2023, and 
$1,082.40 for services provided on September 13, 2023. Additionally, the record shows that the claim for date 
of service September 15, 2023, was received by the Plan prior to the claim for the date of service in this case. 
Claims are processed in the order they are received. Therefore, we decided that the Plan does not have to pay 
an additional amount for the porcelain crown (D2740) provided on September 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 29, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on July 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation with a medicinal agent-per quadrant 
(D4921 x4). 
 
You asked the Plan to pre-approve the dental services. You say that before you went to the dentist you called 
the Plan and were told that cleanings and cleaning treatments are included. You say that gingival irrigation is a 
prevention of cavities so you feel that this should be approved. The Plan denied your request. The Plan says 
this service is not a covered expense 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 
gingival irrigation with a medicinal agent-per quadrant (D4921 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for localized delivery of antimicrobial agents (D4381), gingival 
irrigation (D4921) and other drugs or medicaments dispensed in the office for home use (D9630) provided on 
August 28, 2023. 
 
You asked the Plan to pay for localized delivery of antimicrobial agents (D4381), gingival irrigation (D4921) 
and other drugs or medicaments dispensed in the office for home use (D9630). You say that you are requesting 
reconsideration of the denied dental services. The Plan denied your request. The Plan says there is no coverage 
for these 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 pay for localized 
delivery of antimicrobial agents (D4381), gingival irrigation (D4921) and other drugs or medicaments 
dispensed in the office for home use (D9630) provided on August 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unspecified removable prosthodontic procedure 
(D5899). 
 
You asked the Plan to pre-approve unspecified removable prosthodontic procedure. You say that you were told 
your insurance would cover $2,000 for dentures. The Plan denied your request. The Plan says there is no 
coverage for this 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 
unspecified removable prosthodontic procedure (D5899).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0670). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the enrollee 
has unique characteristics that meet medical necessity policy for the purchase of the E0652 and E0670.  The 
Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced 
lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either 
E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0670).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standard wheelchair provided on August 4, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 standard wheelchair provided on August 4, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the walker and the walker seat to be provided by an 
OON provider.  
 
You asked the Plan to pre-approve the walker and the walker seat. You say that you are requesting 
reconsideration of the denied items. The Plan denied your request. The Plan says the items were not approved. 
 
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 Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 the walker and the walker seat to be provided 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87500, 87652, 87798, 87799, and 
87900 provided on September 5, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87500, 87652, 87798, 87799, and 87900. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87481, 87500, 87652, 87798, 87799, and 87900 provided on September 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on August 10, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the consultation visit to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the consultation. You say that you are requesting reconsideration of the 
denied service. The Plan denied your request. The Plan says the service was not approved. 
 
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 Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 the consultation visit to be provided by an 
OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided on August 
20, 2023, to August 23, 2023. 
 
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you do not agree with the 
cost sharing. 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% 
coinsurance for out-of-network inpatient care. 
 
You have been asked to pay 40% coinsurance for inpatient hospital care. This item/service falls within the out-
of-network inpatient 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. The total you owe is $161.85 ($404.61 allowed amount x 40% = $161.85 rounded up). 
Therefore, we decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided 
on August 20, 2023, to August 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81479 for date of 
service September 10, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed 
with code 81479 for date of service September 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 27, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on July 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker. 
 
You asked the Plan to pre-approve a rollator walker. You say that you have mobility issues and need this item 
to get around and do basics around the house. The Plan denied your request. The Plan says you do not meet 
criteria for the requested device. 
 The Plan must follow Medicare rules. Medicare rules say that walkers are only covered when the enrollee 
meets the following criteria: 
1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADL) in the home. 
2. The beneficiary is able to safely use the walker; and 
3. The functional mobility deficit can be sufficiently resolved with use of a walker. 
 
We looked at the file and Medicare rules. Review of the file does not include medical records to support the 
need for the requested walker. Based on this information, we decided that Medicare rules for coverage of a 
rollator walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a rollator 
walker.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 9, 2023. 
 You asked the Plan to pay for the ED services. You say that the Medicare enrollment letter has been provided. 
The Plan denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  The Medicare billing privileges for this provider were temporary and 
expired at the end of the PHE. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and the related 
supply allowance. 
 
You asked the Plan to pre-approve the CGM and related supply allowance. You say that you are appealing the 
denied CGM. The Plan denied your request. The Plan says the Medicare coverage 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. Specifically, the request for additional information from your 
physician indicates that you do not use insulin or have a history of problematic hypoglycemia. Based on this 
information, we decided that Medicare rules for coverage of the CGM and related supply allowance have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM) and the related supply allowance.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network pain management 
provider. 
 
You asked the Plan to pre-approve these services. You say that the in-network provider is 110 miles from your 
residence. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage rules that apply.) The file shows that the network provider is located 110 miles from your residence by driving 
distance; however, the requested provider is located 1,460 miles from your residence by driving distance. We 
found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that 
the Plan does not have to pre-approve a referral to an out-of-network pain management provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 7, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
documents needed for payment. The Plan denied your request. The Plan says the documentation requirements 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on July 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6197, A6253, and A4450 provided on 
August 23, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure codes A6197, A6253, and A4450. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided 
were neither emergent nor urgent and prior authorization was not obtained to provide OON care. 
 
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 had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 
procedure codes A6197, A6253, and A4450 provided on August 23, 2023, by an out-of-network (OON) 
provider.