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

 
We decided that the Plan does not have to pay for dental services provided on June 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum 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 $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring provided on April 30, 2023. 
 
You asked the Plan to pay for the remote monitoring. 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 remote monitoring 
provided on April 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan provided on August 3, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for a CT scan. You say that the provider did not inform you that the scan was not 
approved prior to the service being rendered. The Plan denied your request. The Plan says the prior 
authorization requested was not approved as there are in-network providers available to perform the service 
requested. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a CT scan provided on August 3, 2023, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology provided on June 07, 2023. 
 
You asked the Plan to pay for surgical pathology. You say that you are request reconsideration of the attached 
claims because the doctors office failed to send in a pre-authorization form for approval. 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 surgical pathology 
provided on June 07, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. 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 pre-approve Buprenorphine.   
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an amalgam (D2150) provided by an out-
of-network provider on June 6, 2023. 
 You asked the Plan to waive the coinsurance for the dental service. You say that you were never told you 
would have copayments for dental coverage because you did not prior to 2023. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for non-Medicare covered comprehensive dental services. The total amount allowed for the 
amalgam was $184 and the total coinsurance was $36.80 ($184 allowed x 20% coinsurance). 
 
You have been asked to pay a 20% coinsurance for the dental service. This item/service falls within the dental 
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 an amalgam (D2150) 
provided by an out-of-network provider on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified maxillofacial prosthesis (D5999) provided on 
June 26, 2023. 
 
You asked the Plan to pay for the dental service. You say that the service is a medical claim sent over by the 
dentist and it should be covered under a sleep apnea device. The Plan denied your request. The Plan says the 
services requested are purely dental in nature. The services are not eligible for coverage under the medical 
benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The requested unspecified maxillofacial prosthesis in dispute meets the Medicare definition of dental, since it is 
a service which involved the care and treatment of teeth or structures directly supporting the teeth. The 
unspecified maxillofacial prosthesis does not fall under any of Medicare exceptions for coverage of non-routine 
dental care. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that 
the Plan does not have to pay for an unspecified maxillofacial prosthesis (D5999) provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 
provided by an out-of-network provider who is not certified with Medicare on June 8, 2023. You asked the Plan to pay for the compression stockings. You say that the compression sleeve is a durable 
medical equipment, and it should be covered. The Plan denied your request. The Plan says the denial of 
payment is correct, because the provider is not a Medicare certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Also, the compression stocking if received by a participating provider would not be covered because 
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 pay for the compression stockings identified with code A6549 provided 
by an out-of-network provider who is not certified with Medicare on June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation  problem focused (D0140) provided 
on July 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 July 7, 2023, and July 12, 
2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation  problem focused 
(D0140) provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation therapy (97014), manual therapy 
(97140), chiropractic manipulative treatment (98941) and the office visit (99214) provided by a chiropractor on 
July 7, 2023, to August 7, 2023. 
 
You asked the Plan to pay for the electrical stimulation therapy (97014), manual therapy (97140), chiropractic 
manipulative treatment (98941) and the office visit (99214). You say that you had a weeks worth of successful 
treatment and following that you had reinjured your back. You say that you were told that you have a 
compression fracture and would like to have additional visits covered. The Plan denied your request. The Plan 
says the benefit has been exhausted. 
 
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. However, the Plan offered a chiropractic benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The plan covers a 
maximum of 6 routine visits every year.  The records show that the service at issue is not manual manipulation of the spine to correct subluxation. The 
records also show that you have exhausted the Plans benefit for routine visits. Therefore, we decided that the 
Plan does not have to pay for the electrical stimulation therapy (97014), manual therapy (97140), chiropractic 
manipulative treatment (98941) and the office visit (99214) provided by a chiropractor on July 7, 2023, to 
August 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
February 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that according to the dental offices, the regular 
dentist got approval for a root canal and aid you had coverage to pay for it. 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 December 15, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on February 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopic procedure provided on 
August 09, 2023. 
 
You asked the Plan to waive the copayment for an endoscopic procedure. You say that you say that you cannot 
afford 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 $175 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $175 copayment for an endoscopic procedure. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 endoscopic procedure 
provided on August 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on July 19, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this was 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 March 14, 2023. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided 
on July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occlusal guard full arch (D9944) provided on June 13, 2023. 
 
You asked the Plan to pay for occlusal guard full arch. You say that the mouth guard was medically necessary 
to treat constant headaches from teeth grinding. 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 pay for occlusal 
guard full arch (D9944) provided on June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the electrocardiogram (ECG) provided on 
June 19, 2023. 
 
You asked the Plan to pay for the office visit and the electrocardiogram (ECG). You say that you are appealing 
the denial with supporting documentation. 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 the 
electrocardiogram (ECG) provided on June 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that the provider told you that the Plan would cover the 
inserts. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.   
  Your complaint about the provider telling you the wrong information is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drug injections provided 
on May 22, 2023, to June 28, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drug injections. You say that you do not 
understand why the cost share is different from previous injections 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 Medicare Part B drug 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. You have been asked to pay $48.87, which is 20% of the total allowed 
amount for the Medicare Part B drug injections ($244.34 allowed x 20% = $48.87). Therefore, we decided that 
the Plan does not have to waive the coinsurance for Medicare Part B drug injections provided on May 22, 2023, 
to June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on January 05, 2023, to March 15, 
2023. 
 
You asked the Plan to pay for diabetic supplies. You say that wound care supplies are a separately billable 
expense that does not require authorization or referral. 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 diabetic supplies 
provided on January 05, 2023, to March 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve single photon emission computed tomograph (SPECT) 
imaging (78452). 
 
You asked the Plan to pre-approve SPECT imaging. You say that this service is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that single photon emission computed tomograph 
(SPECT) imaging is covered when 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 SPECT imaging. Our reviewer says that 
this service is not medically necessary. Our physician reviewer found the patient has no cardiovascular signs or 
symptoms. There is no documentation that the electrocardiogram shows an uninterpretable pattern. There is no 
evidence provided that would support the need for radionuclide stress testing at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT imaging have not been met. Therefore, we decided that the Plan does 
not have to pre-approve single photon emission computed tomograph (SPECT) imaging (78452).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the screening cytopathology on June 05, 
2023. 
 
You asked the Plan to waive the cost share for the screening cytopathology. You say that according to the 
EOC, the service should be covered at 100%. 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 there is no 
coinsurance, copayment, or deductible for Medicare-covered preventive Pap and pelvic exams. Covered 
services include for all women: Pap tests and pelvic exams are covered once every 24 months. If you are at 
high risk of cervical or vaginal cancer or you are of childbearing age and have had an abnormal Pap test within 
the past 3 years: one Pap test every 12 months. The provider billed in the amount of $99.75. Therefore, results 
in the total cost shairng amount of $99.75. 
 
You have been asked to pay a $99.75 cost share for screening cytopathology. This item/service falls within the 
cervical and vaginal cancer screening 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 cost share for the 
screening cytopathology on June 05, 2023.