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

 
We decided that the Plan does not have to waive the copayment for a medical eye exam provided on June 07, 
2023. 
 
You asked the Plan to waive the copayment for a medical eye exam. You say that you were told that there 
would not be a cost share. 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 $50 
copayment for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, 
including treatment for age-related macular degeneration. 
 
You have been asked to pay a $50 copayment for a medical eye exam. This item/service falls within the outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including 
treatment for age-related macular degeneration 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 medical eye exam provided on June 07, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6534. 
 
You asked the Plan to pre-approve the compression stockings. You say that your left foot is swollen three times 
the size. The Plan denied your request. The Plan says compression stockings for an edema condition is not a 
Medicare covered benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6534.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #15. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a retainer crown (D6740) for tooth #18, #21, and #22 on March 28, 2023; therefore, 
your benefit for the requested item or service was exhausted on the date of service of March 28, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hearing evaluation (and/or hearing aids) with a non-
contract provider. 
 You asked the Plan to pre-approve a hearing evaluation (and/or hearing aids) with a non-contract provider. You 
say that you are appealing with supporting records. The Plan denied your request. The Plan says you must get 
care 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 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. 
 
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 services are obtained from an in-network Plan provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing evaluation (and/or hearing aids) with a non-contract provider have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a hearing evaluation (and/or hearing aids) 
with a non-contract provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve the occlusal guard. You say that your doctor informed you that you need the 
mouth guard because you are grinding your teeth. You also say that this is a recommendation from a 
professional that has indicated this is urgent to prevent future damage to your teeth and oral health. The Plan 
denied your request. The Plan says this service is not covered in your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard  hard appliance, full arch (D9944).
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 extra rides for your dialysis 
appointments that are three times a week. You also say that you have used your transportation allowance. The 
Plan denied your request. The Plan says your request exceeds the benefit limit for the transportation program.  
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 
additional trips for your dialysis appointments. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional routine transportation trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown (D6752). 
 
You asked the Plan to pre-approve retainer crown. 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 
retainer crown (D6752).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #23 and #24. 
 
You asked the Plan to pre-approve the dental services. You say that you only did 1 this year and you would like 
the case to be re-evaluated. The Plan denied your request. The Plan says your benefit for the requested items or 
services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved a pontic (D6240) for tooth #25 and #36 and a retainer crown (D6750) for tooth 
#22 and #27 on June 30, 2023; therefore, your benefit for the requested items or services was exhausted on the 
date of approval of June 30, 2023. Therefore, we decided that the Plan does not have to pre-approve a pontic 
(D6240) for tooth #23 and #24.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), an 
implant (D6057), the custom fabricated abutment (D6057), and the abutment supported to crown (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that you were told bridge work i covered and 
you need the implant to support the permanent bridge. The Plan denied your request. The Plan says the denial 
of authorization for these services is correct, because dental implant and all associated services are not covered 
by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of implant body (D6010), an implant (D6057), the custom fabricated abutment (D6057), 
and the abutment supported to crown (D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on May 24, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing this denial. 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 nursing facility care 
provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement graft (D7953) for tooth #2. 
 
You asked the Plan to pre-approve the dental service. You say that you are experiencing extreme pain and the 
procedure would improve your life. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because the bone replacement graft is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
bone replacement graft (D7953) for tooth #2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750) provided on March 24, 2023. 
 
You asked the Plan to pay for anti-reflective coating (V2750). You say that according to the Plan's policy, you 
are entitled to an annual vision checkup and one prescription at no extra charge. The Plan denied your request. 
The Plan says per the plan benefit chart, this is a non-covered service, although the plan does offer a discount 
for anti-reflective coating with a $30.00 surcharge. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the lenses are standard only. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan pays up to $100 toward your 
purchase of frames (with standard lenses covered in full). The Plan rules also say that options that are not 
covered include anti-reflective coating. Based on this information, we decided that the Plan's rules for coverage 
of anti-reflective coating (V2750) have not been met. Therefore, we decided that the Plan does not have to pay 
for anti-reflective coating (V2750) provided on March 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement tooth 30 (D6010), custom abutment 
tooth 28 and 30 (D6057); abutment supported porcelain fused to metal crown (high noble metal) tooth 28 and 
30 (D6059), and bone replacement graft for ridge preservation - per site tooth 28 and 30 (D6240). 
 
You asked the Plan to pre-approve implant and associated services and a bone graft. You say that this should 
be covered. The Plan denied your request. The Plan says the implant placement is denied due to our records 
show you have gotten a partial denture to replace this tooth within the past sixty (60) months or we have 
recently approved a partial denture to replace this tooth. The other services cannot be approved without the 
implant.  
 
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 
implant placement tooth 30 (D6010), custom abutment tooth 28 and 30 (D6057); abutment supported porcelain 
fused to metal crown (high noble metal) tooth 28 and 30 (D6059), and bone replacement graft for ridge 
preservation - per site tooth 28 and 30 (D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gym membership with an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not a covered benefit.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
The Plans rules for coverage of gym benefits have not been met because you have requested a gym 
membership with an out-of-network provider. The Plans contract states that supplemental coverage is 
provided for a fitness benefit only when rendered by the Plans select fitness provider. Therefore, we decided 
that the Plan does not have to pre-approve a gym membership with an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft  retained natural tooth  first 
site in quadrant (D4263). 
 
You asked the Plan to pre-approve the bone replacement graft. You say that the dental code is existing but not 
eligible under your dental plan. You also say that you have been advised on several occasions without promise 
to send the documents to enter validation and was denied again because it is not covered. The Plan denied your 
request. The Plan says the requested dental service is not included on 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone 
replacement graft  retained natural tooth  first site in quadrant (D4263).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of erupted tooth (D7210) for tooth 
#15 and #16 and the analgesia (D9230). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain, and you are having a hard 
time eating and drinking. The Plan denied your request. The Plan says your benefit for the surgical removal of 
erupted tooth has already been exhausted. Also, the analgesia is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved the surgical removal of erupted tooth (D7210) for tooth #1 on June 12, 2023; 
therefore, your benefit for the surgical removal of erupted tooth was exhausted on the date of approval of June 
12, 2023. The analgesia is not covered under the Plans dental benefit. Therefore, we decided that the Plan does 
not have to pre-approve the surgical removal of erupted tooth (D7210) for tooth #15 and #16 and the analgesia 
(D9230).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on May 03, 2023. 
 
You asked the Plan to pay for physical therapy. You say that the out-of-network provider is able to come to 
your home. 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 May 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Botox injections provided on May 03, 
2023. 
 
You asked the Plan to waive the coinsurance for Botox injections. You say that you disagree with the 
copayment applied for the injection received. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Botox injections. This item/service falls within the Medicare 
Part B prescription drugs 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 $252.76, which is 20% of the allowed amount for Medicare Part B 
drug injections ($1,263.81 allowed x 20% = $252.76). Therefore, we decided that the Plan does not have to 
waive the coinsurance for Botox injections provided on May 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Lite test strips. 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that you were told by someone at the 
Plan that the Freestyle test strips were covered. The Plan denied your request. The Plan says only the preferred 
brand products listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve the Freestyle 
Lite test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix glucose test strips. 
 You asked the Plan to pre-approve the test strips. You say that the test strips are a medical necessity. The Plan 
denied your request. The Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the test strips. Therefore, we decided that the Plan does not have to pre-approve True Metrix glucose test 
strips.