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

 
We decided that the Plan does not have to pay for the genetic testing provided on April 17, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that this is supported in the records. 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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the genetic testing provided on April 17, 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 an office visit, and related services provided on May 08, 
2023. 
 
You asked the Plan to pay for an office visit, and related services. You say that it was medically necessary for 
the provider to perform these services. 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 an office visit, and 
related services provided on May 08, 2023.
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 the CGM. You say that the CGM is medically necessary for the enrollee's 
medical condition. 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 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. Specifically, the request for information from the enrollees 
physician indicates that the enrollee does not have diabetes. Based on this information, we decided that 
Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services to assist with personal care. 
 
You asked the Plan to pre-approve home health aide services. You say that you are unstable, and you require 
assistance with bathing. The Plan denied your request. The Plan says the denial for the home health aide 
services is correct because the services requested is to help with your personal care or housekeeping needs. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health aide services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home 
health aide services to assist with personal care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 1, 2022. 
 
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 $2,500 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 benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pay for dental services provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010), a 
custom fabricated abutment (D6057), an abutment support to crown (D6059), and the sinus augmentation 
(D7952) for tooth #13 and #14. 
 
You asked the Plan to pre-approve the dental services. You say that you need the dental implant because you 
cannot chew properly. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because dental implants and all related services along with the sinus augmentation are not 
covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of implant body (D6010), a custom fabricated abutment (D6057), an abutment support to 
crown (D6059), and the sinus augmentation (D7952) for tooth #13 and #14.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on February 22, 2023. 
 You asked the Plan to pay for the ambulance services and ground mileage. You say that this was not billed as 
an emergent run. You also say to please review this claim and reprocess for payment. The Plan denied your 
request. The Plan says a physicians office is not a covered destination. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport, and ground mileage provided on February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network wound repair procedure 
provided on March 21, 2023. 
 
You asked the Plan to waive the copayment for an in-network wound repair procedure. You say that you 
thought you were only going to be charged the $40 specialist copay, not this larger surgical copay. You cannot 
afford these larger copays and were not made aware that you would be charged that way. 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 $270 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  You have been asked to pay the allowed amount of $219.82 which is less than the $270 copayment for an in-
network wound repair 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 in-network wound repair procedure provided on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for polycarbonate lenses (V2784), frames (V2020) and 
sales tax (S9999) provided on December 16, 2022. 
 
You asked the Plan to reimburse for polycarbonate lenses (V2784), frames (V2020) and sales tax (S9999). You 
say that you did not get a point of service deduction of $105, therefore, the Plan owes you the $105 
reimbursement. The Plan denied your request. The Plan says you have already utilized the benefit amount. 
 
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 reimburses up to $105 every year for non-Medicare covered prescription eyewear. 
 
We looked at the file and the Plan's rules. The rules say that the Plan reimburses up to $105 every year for non-
Medicare covered prescription eyewear. You are responsible for any amount above the eyewear coverage limit. 
The record shows this benefit was exhausted on December 16, 2022. Based on this information, we decided 
that the Plan's rules for coverage of polycarbonate lenses (V2784), frames (V2020) and sales tax (S9999) have 
not been met. Therefore, we decided that the Plan does not have to reimburse for polycarbonate lenses 
(V2784), frames (V2020) and sales tax (S9999) provided on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolonged evaluation and management services provided on 
November 21, 2022. 
 
You asked the Plan to pay for prolonged evaluation and management services. You say that these services were 
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 prolonged evaluation 
and management services provided on November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for clinical crown lengthening - hard tissue (D4249) provided on 
January 25, 2023. 
 
You asked the Plan to pay for clinical crown lengthening - hard tissue. 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 clinical 
crown lengthening - hard tissue (D4249) provided on January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra test strips. 
 
You asked the Plan to pre-approve the OneTouch Ultra test strips. The Plan denied your request. The Plan says 
conditions for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit coverage to certain brands of 
products and this plan only covers Abbott brands (FreeStyle and Precision).  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the OneTouch Ultra test strips have not been met. Therefore, we decided that the Plan does not 
have to pre-approve OneTouch Ultra test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial lower denture (D5214). 
 
You asked the Plan to pre-approve partial lower denture. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010) and abutment supported 
porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve implant and associated services. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant placement (D6010) and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Miacalcin. 
 
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 Miacalcin.   
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift or glide.  
 
You asked the Plan to pre-approve a stair glide. You say that you would like reconsideration because the 
requested stair lift or glide is medically necessary. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift or glide.
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 February 10, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical service responders were able to get your blood pressure back up to a normal range. You 
also say that you refused transport 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 February 10, 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 February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite for tooth #9 (D2332) provided May 
23, 2023. 
 
You asked the Plan to pay for the dental services. You say that the filling broke off and it became jagged. 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 January 12, 2023. Therefore, we decided that the Plan does not have to pay for a resin-based composite for tooth #9 (D2332) 
provided May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for you to get the 
dentures because you cannot chew properly. 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 complete upper denture (D5110) and a partial lower denture (D5214) on June 11, 
2021; therefore, your benefit for the requested items or services was exhausted on the date of service of June 
11, 2021. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) 
and a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic (D6245 x2) and retainer crown (D6740 x2) provided 
on April 3, 2023. 
 
You asked the Plan to pay for pontic and retainer crowns. 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 pontic 
(D6245 x2) and retainer crown (D6740 x2) provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facility services for dental rehabilitation procedures 
(G0330) and the anesthesia for intraoral procedures (00170). 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are necessary for the 
enrollee. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the facility services for dental rehabilitation procedures and the anesthesia for intraoral procedures are 
not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
facility services for dental rehabilitation procedures (G0330) and the anesthesia for intraoral procedures 
(00170).
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 27, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not know this service was not covered. 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 27, 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 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve new dentures. 
 
You asked the Plan to pre-approve 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 April 20, 2023. 
Therefore, we decided that the Plan does not have to pre-approve new dentures.