Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on July 13, 2023. 
 
You asked the Plan to pay for the laboratory service. 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 laboratory service 
provided on July 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
June 23, 2022. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that you did not request 
this transport, and therefore feel you should not have to pay this 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for an in-network ambulance ride. This item/service falls within 
the ambulance 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 an in-
network ambulance ride provided on June 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) study of the 
cervical spine, lumbar spine, and lower extremities. 
 
You asked the Plan to pre-approve the MRI studies. You say that the MRI studies are medically necessary due 
to the severe pain you are experiencing and for you to receive the proper treatment.  The Plan denied your 
request. The Plan says there is not enough information provided to determine the medical need for the 
requested services. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the MRI studies have been met. 
Medical records to show why the MRI scans are needed. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI) study of the cervical spine, lumbar spine, and lower 
extremities.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from March 19, 2023, to 
March 24, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication should be paid for by the Plan. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from March 19, 2023, to March 24, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and laboratory service provided on June 19, 
2023. 
 
You asked the Plan to pay for the office visit and laboratory service. 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 and 
laboratory service provided on June 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of fluoride (D1206) provided on August 8, 
2023. 
 
You asked the Plan to pay for the dental service. You say that last year you had 3 fluoride treatments covered 
by the Plan and nowhere does it show your coverage has changed. 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 the application of fluoride (D1206) on January 19, 2023, and June 5, 2023; therefore, 
your benefit for the requested item or service was exhausted on the date of service of June 5, 2023. Therefore, 
we decided that the Plan does not have to pay for the application of fluoride (D1206) provided on August 8, 
2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81003 provided on May 18, 2023. 
 
You asked the Plan to pay for procedure code 81003. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the medical records submitted do not 
include a physician order or laboratory requisition for the billed test. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 81003 is Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, 
nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without 
microscopy. 
 
We find that CPT code 81003 is supported in the medical record. Specifically, the file shows a requisition form 
completed by the contracted ordering provider was provided, along with the laboratory report confirming that a 
urinalysis for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and 
urobilinogen was completed. Based on this information, we decided that Medicare rules for coverage of 
procedure code 81003 have been met. Therefore, we decided that the Plan has to pay for procedure code 81003 
provided on May 18, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on April 10, 2023. 
 
You asked the Plan to pay for a chiropractic visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a chiropractic visit 
provided on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on July 18, 2023. 
 
You asked the Plan to pay for eyeglasses. You say that you were informed that the cost of the eyeglasses would 
be much less if you were paying cash, but that the chain optical store you were accessing had found a way to 
maximize profits, and charge more for being in-network. The Plan denied your request. The Plan says you self-
referred to a non-participating provider. 
 
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 you obtain vision services from an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that any benefit received at a non-network optical 
provider is excluded from this benefit. Based on this information, we decided that the Plan's rules for coverage 
of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses 
provided on July 18, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 10, 
2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you feel that you should not be 
responsible for the copay because its the provider who ordered it because the doctor could not see anything. 
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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown-porcelain/ ceramic tooth 31 (D2740) provided on 
November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that this is medically necessary. 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 your benefit for the requested item or service was exhausted on date of service September 19, 2018. 
Therefore, we decided that the Plan does not have to pay for crown-porcelain/ ceramic tooth 31 (D2740) 
provided on November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on April 06, 2023. 
 
You asked the Plan to pay for the home 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 home visit provided 
on April 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray, the neck x-ray, and the lower back x-ray 
provided on July 18, 2023. 
 
You asked the Plan to pay for the chest x-ray, the neck x-ray, and the lower back x-ray. You say that you did 
not know that chiropractors could not bill for x-rays that were ordered. The Plan denied your request. The Plan 
says the services are not covered benefits. 
 
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 services at issue are not manual manipulations of the spine. Therefore, we decided 
that the Plan does not have to pay for the chest x-ray, the neck x-ray, and the lower back x-ray provided on July 
18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), a complete 
maxillary denture (D5110) and a complete mandibular denture (D5120) provided on May 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you got a set of dentures in 2021 and they the 
provider never made them fit right. 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 your benefit for a panoramic radiographic image (D0330), a complete maxillary denture (D5110) was 
exhausted on date of service November 4, 2021. The record also shows that your benefit for a complete 
mandibular denture (D5120) was exhausted on date of service November 16, 2021. Therefore, we decided that 
the Plan does not have to pay for a panoramic radiographic image (D0330), a complete maxillary denture 
(D5110) and a complete mandibular denture (D5120) provided on May 18, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the walker (E0147) provided on April 26, 2023. 
 
You asked the Plan to pay for the walker (E0147). You say that you were under the impression from the 
provider that you would only have to pay for the laser light and basket. You say that you thought the walker 
would still be paid for by the Plan. The Plan denied your request. The Plan says that the services are not 
covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. The enrollee was referred for the walker (E0147) by a contract provider. The file 
does not show that the plan provided notice that the walker (E0147) would not be covered. Under Medicare 
rules, this means the walker (E0147) is considered approved by the plan. 
 
The rules also say the Advance Beneficiary Notice (ABN) is given to beneficiaries enrolled in the Medicare 
FFS program. It is not used for items or services provided under the Medicare Advantage (MA) Program. 
Medicare states that ABNs are not to be used for Medicare Advantage enrollees. The walker coded as E0147 is 
covered under Medicare when criteria are met. The ABN in this case is also defective in that the provider 
should have been aware that a walker coded as E0147 is covered under Medicare. To be a valid ABN, the 
beneficiary must understand the meaning of the notice and the appeal clearly demonstrates the enrollee 
believed the walker would still be covered. Therefore, we decided that the Plan has to pay for the walker 
(E0147) provided on April 26, 2023.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

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

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341 and 
D4342) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that you need the treatment so you can get your 
teeth healthy. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because the periodontal scaling and root planing 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
periodontal scaling and root planing (D4341 and D4342) for all 4 quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) and core buildup (D2950) for tooth 
#18 provided by an out-of-network provider on October 18, 2022. 
  You asked the Plan to pay more for the dental services. You say that you were unaware of frequency limits, 
and you are appeal the dental claims. The Plan denied your request. The Plan says you are responsible for any 
charged amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a crown (D2740) and core buildup (D2950) 
for tooth #18 provided by an out-of-network provider on October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) machine and 
other supplies provided on September 03, 2022. 
 
You asked the Plan to pay for the continuous positive airway pressure (CPAP) machine and other supplies. 
You say that you believe that if the provider had been more accurate in the process this never would have 
happened. 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 continuous positive 
airway pressure (CPAP) machine and other supplies provided on September 03, 2022.