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

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the dental service. You say that you have problems with your teeth, and it is 
medically necessary to get the denture. The Plan denied your request. The Plan says dental services from an 
out-of-network provider are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested item or service is not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a partial 
upper denture (D5213) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on January 28, 2023. 
 
You asked the Plan to pay for ophthalmological services. You say that you say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments. 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 ophthalmological 
services provided on January 28, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health provided on October 19, 2022. 
 
You asked the Plan to pay for outpatient mental health. You say that you believe the services are medically 
necessary. 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 outpatient mental health 
provided on October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the laboratory services provided on January 
16, 2023. 
 
You asked the Plan to waive the deductible for the lab services. You say that you disagree with the 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. Your 
contract with the Plan says that there is a $226 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
 
 You have been asked to pay $95.90 towards your deductible for the lab services. The items or services you 
asked the Plan to waive the deductible for fall within the outpatient diagnostic tests and therapeutic services 
and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $226 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. 
This cost sharing is a contractual obligation that had not been met at the time the lab services was received on 
January 16, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory 
services provided on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
January 11, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow-up 
visit and you should not be charged. 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 the specialist office visit provided on January 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a colonoscopy provided on March 06, 2023. 
 
You asked the Plan to pay for a colonoscopy. 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 colonoscopy provided 
on March 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup (D2950) provided on January 23, 2023. 
 
You asked the Plan to pay for a core buildup. 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 pay for a core 
buildup (D2950) provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110), an immediate upper 
denture (D5130), and an immediate lower denture (D5140). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain, and you want a complete 
denture for the upper and the lower mouth. 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 paid for a lower partial denture on February 25, 2021, and paid for an upper partial denture on 
May 13, 2021; therefore, your benefit for the immediate lower denture was exhausted on the date of service of 
February 25, 2021, and your benefit for the complete and immediate upper denture was exhausted on the date 
of service of May 13, 2021. Therefore, we decided that the Plan does not have to pre-approve a complete upper 
denture (D5110), an immediate upper denture (D5130), and an immediate lower denture (D5140).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on February 20, 2023. 
 
You asked the Plan to pay for lab testing. You say that you believe the services are medically necessary. 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 lab testing provided on 
February 20, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on November 08, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment 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 November 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 25, 2023 by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that you were not told this provider was out-of-
network until after these services were provided. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on January 25, 2023 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional non-emergency transportation trips 
(A0100). 
 You asked the Plan to pre-approve 10 ten additional non-emergency transportation trips. You say that you need 
the transportation for your magnetic resonance imaging appointments (MRI's). The Plan denied your request. 
The Plan says your non-emergent transportation limit has been reached. 
 
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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve 10 
additional non-emergency transportation trips. 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 10 additional non-emergency transportation trips (A0100).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on February 20, 2023. 
 
You asked the Plan to pay for the medication. You say that you should not be responsible for something that 
was ordered by your doctor. 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 
on February 20, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on February 17, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this code is included in the 
global surgery package of code 20610 that was billed on the same date of service. Based on this information, 
we decided that Medicare rules for coverage of procedure code J3490 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code J3490 provided on February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower 
denture (D5120) provided on February 3, 2023. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the dental items provided 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 dental items provided was exhausted on date of service November 18, 2020.  
  
 
Specifically, the Plans contract provides coverage for one complete upper denture and one complete lower 
denture every 60 months. You previously received these dental items on November 18, 2020, less than 60 
months prior, which were paid for by the Plan. Therefore, you have exhausted the allowable benefit for these 
dental items. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) 
and the complete lower denture (D5120) provided on February 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the intermittent catheters provided from 
October 25, 2022, to February 14, 2023. 
 
You asked the Plan to waive the coinsurance for the catheters. You say that this item should not be considered 
durable medical equipment. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for in-network Medicare-covered medical supplies.  The enrollee has been asked to pay $80.40, with is 20% coinsurance of the allowed amount for each catheter 
provided on October 25, 2022, December 19, 2022, and February 6, 2023 ($402.00 allowed amount x 20% = 
$80.40). The enrollee has also been asked to pay $64.32, which is 20% coinsurance of the allowed amount for 
the catheter provided on February 14, 2023 ($321.60 allowed amount x 20% = $64.32). These items/services 
fall within the prosthetic devices and related supplies benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the coinsurance for the intermittent catheters provided from October 25, 2022, to February 14, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (81162, 81201, 81218, 81292-90, 81295, 81298, 
81307, 81317, 81321, 81351, 81209, 81314, 81334, 81345, 81272) provided on January 9, 2023.  
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this test was for screening purposes and is non-covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a genetic testing panel, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for lab testing (81162, 81201, 81218, 81292-90, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 81314, 
81334, 81345, 81272) provided on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek test strips. 
 
You asked the Plan to pre-approve the Accu-Chek test strips. The Plan denied your request. The Plan says only 
the preferred brand products listed in the EOC are covered. There is no evidence that the preferred product 
OneTouch would not meet the member's needs. 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 Accu-Chek test strips. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek test 
strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation - established patient 
(D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided on February 
13, 2023. 
 
You asked the Plan to pay more for the dental services. You say that it is your understanding is that you had 
$1,000 per year and 2 dental cleanings. You also ask why the charges are not being paid in full. 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 periodic oral evaluation - established 
patient (D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided on 
February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on February 8, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not payable as they were rendered by 
an out-of-network provider.  
 
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 provided by the Plans select hearing aid vendor.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when provided by the Plans select hearing aid vendor. However, the hearing aids in this case were 
rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
hearing aids (V5261) provided on February 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on March 07, 2023. 
 
You asked the Plan to pay for lab testing. You say that you say that you cannot anticipate the need for 
authorization until the sample is received. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
March 07, 2023.