Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on April 17, 2023, to May 29, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you disagree 
with the copayments applied to the services provided. 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 $25 
copayment for outpatient rehabilitation services.  
You have been asked to pay a $25 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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. The total copayment you owe is $125 for PT services ($25 per visit x 5 
visits = $125). Therefore, we decided that the Plan does not have to waive the copayment for each physical 
therapy (PT) visit provided on April 17, 2023, to May 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5261) provided on March 31, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5261). You say that you were told that in additional to 
going through the Plan vendor, you would be reimbursed an additional $500 for the particular hearing aids you 
purchased. The Plan denied your request. The Plan says you were already reimbursed the maximum allowable 
amount for your hearing aid benefit. 
 
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 covers up to 
a $500 reimbursement for a hearing aid every 3 years. 
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5261) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5261) provided on March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on February 22, 2023. 
 
You asked the Plan to pay for the core buildup. You say that you agreed to 2 crowns and was left with the  
assistant for over an hour. The Plan denied your request. The Plan says your benefit for the core buildup $1,500 
dollar limit was met. 
 
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 service was exhausted on date of service February 22, 2023.  Therefore, we decided that the Plan does not have to pay for core buildup, including any pins when required 
(D2950) provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
April 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told by the dental office that the 
services would be covered by insurance as does the member benefits. You also say that now you have a bill and 
cant understand why it wasnt covered. The Plan denied your request. The Plan says your benefit for the 
panoramic radiographic image 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, the 2D oral/facial photographic image 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on April 27, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service April 27, 2023. You 
already received the allowed frequency of one on the appealed claim as a complete series (D0210). The 
additional panoramic x-ray on the same visit is denied correctly. Therefore, we decided that the Plan does not 
have to pay for the panoramic radiographic image (D0330) provided on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy, and occupational therapy services 
provided from April 3, 2023, to April 25, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physical therapy, and occupational therapy services. You say that you were 
told authorization was not required. The Plan denied your request. The Plan says enrollees must receive their 
care from a network provider. 
 
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 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy, and occupational therapy 
services provided from April 3, 2023, to April 25, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guidance for radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that this is a covered service and medically 
necessary. The Plan denied your request. The Plan says this type of radiation therapy guidance is not needed or 
effective for the enrollee's skin cancer.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 the requested services. Our physician 
reviewer found that when treating skin cancers, there is generally not a need for image guidance unless deep 
structures are being treated. Daily simple simulations for which need has not been established by published 
data or supported by consensus guidelines is not necessary. Daily image guided radiation therapy would not be 
furnished in accordance with accepted standards of medical practice.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve image guidance for radiation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a periodic oral evaluation - established 
patient (D0120), and prophylaxis - adult (D1110) provided on June 5, 2023. 
 
You asked the Plan to waive the coinsurance for the periodic oral evaluation and prophylaxis - adult. You say 
that prior to the 2023 plan year your services with this provider were covered at the 100% benefit level. You 
also say that you have always gotten two cleanings a year and this provider has never been out-of-network. 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 50% 
coinsurance of the total allowed amount for all routine (preventive and comprehensive) out-of-network dental 
services, up to a $1,000 annual maximum.  You have been asked to pay 50% coinsurance for the periodic oral evaluation and prophylaxis - adult . This 
service falls within the dental services (supplemental) 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 a periodic oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) 
provided on June 5, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an ultrasound provided on April 20, 2023. 
 
You asked the Plan to reduce the copayment for an ultrasound. You say that you should only be charged a $30 
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 $150 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for an ultrasound. This item/service falls within the in-network 
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 reduce the copayment for an ultrasound provided on April 20, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit provided by an out-of-network 
provider on April 17, 2023. 
 You asked the Plan to pay for the emergency room visit. You say that you have provided the medical records 
for reconsideration and would like the claim paid. The Plan denied your request. The Plan says the denial of 
payment is correct because the Plan is not the primary insurance company. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan says that the 
benefits were coordinated with the enrollee, provider, and other insurance to provide an explanation of benefits 
from the primary insurance prior to the Plan making a payment. As the secondary insurer, the Plan cannot be 
held responsible for the emergency room visit until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for an emergency room visit provided by an out-of-
network provider on April 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre and supplies. 
 
You asked the Plan to pre-approve a Freestyle Libre and supplies. You say that a CGM is medically necessary. 
The Plan denied your request. The Plan says you do not meet Medicare criteria for a CGM. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 a Freestyle Libre and supplies. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found that we are not told that 
you are having any low blood sugars. Also, there is no documentation in the office notes that you are using 
insulin. Therefore, coverage criteria are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Freestyle Libre and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Freestyle Libre and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration, endosteal implant, and bone graft 
(D6010, D6104, D4266) provided on April 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 guided 
tissue regeneration, endosteal implant, and bone graft (D6010, D6104, D4266) provided on April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - two surfaces, posterior (D2392) 
provided on June 5, 2023. 
 
You asked the Plan to pay for the resin-based composite. You say that under your benefit coverage it is stated 
that you are covered with restorative dental benefits. You also say that you are being billed for the service. 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-based 
composite - two surfaces, posterior (D2392) provided on June 5, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee requires services as they are unable to 
care for themselves. The Plan denied your request. The Plan says the enrollee fails to meet the criteria due to 
the lack of need for skilled therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an out-of-network oncology visit provided on May 
11, 2023. 
 
You asked the Plan to waive the cost for an out-of-network oncology visit. You say that it is ridiculous that the 
Plan did not cover these charges. They need to it is too much to pay. 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 $210 
copayment for Medicare-covered radiological diagnostic services, and a 40% coinsurance for out-of-network 
specialist visits.  You have been asked to pay the allowed amount of $177.12 which is less than the $210 copayment for 
Medicare-covered radiological diagnostic services. You have a 40% ($48.24) coinsurance for out-of-network 
specialist visits. This results in a $225.36 cost ($177.12 + $48.24 = $225.36). 
 
You have been asked to pay a $225.36 cost for an out-of-network oncology visit. This item/service falls within 
the Medicare-covered radiological diagnostic services, and out-of-network specialist 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 cost for an out-of-network oncology visit provided on May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350), and intraoral - complete series of radiographic images (D0210) provided on May 24, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the office stated that there would be no member 
portion for the date of service. The Plan denied your request. The Plan says your benefit for the intraoral - 
complete series of radiographic images has already been exhausted. The Plan also says there is no coverage for 
D0350 2D oral/facial photographic image obtained intra-orally or extra-orally. 
 
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 2D oral/facial photographic image 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on May 24, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested intraoral - complete series of radiographic images was exhausted on date 
of service May 24, 2023. The complete series full mouth and panoramic film have a shared frequency and are 
covered one procedure code every five calendar years. You already received the allowed frequency of D0330 
panoramic radiographic image on the appealed claim. You also received an additional two D0210 intraoral - 
complete series of radiographic images at the same visit. Therefore, we decided that the Plan does not have to 
pay for the intraoral - complete series of radiographic images (D0210) provided on May 24, 2023. 
 
Your complaint about the dental practice 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 30, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
services should be covered as they treated your wound and advised the bleeding would stop soon. The Plan 
denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 30, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on April 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM). You asked the Plan to pay for the supply allowance for the CGM. You say that you are appealing the denied 
supply allowance. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the supply allowance for the CGM have not been met. Therefore, we decided that the Plan does not have to pay 
for the supply allowance for a continuous glucose monitor (CGM).