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

 
We decided that the Plan does not have to pay for hearing aids (V5261) provided on March 31, 2023. 
 
You asked the Plan to pay for hearing aids (V5261). You say that you were told by a Plan representative that 
you were covered. You also say that the representative did not mention that you had to go through a Plan 
specific hearing vendor. The Plan denied your request. The Plan says the Plan requires hearing aids to be 
obtained from our in-network supplier. 
 
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 the hearing aids are obtained through the Plan specific hearing vendor.  
 
 
  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 pay 
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 dental services provided by Mark H. Freeland an out of 
network (OON) provider on May 2, 2023. 
 
You asked the Plan to pay for dental services. You say that you were referred here and needed immediate 
attention. The Plan denied your request. The Plan says providers who have opted out of Medicare are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by Mark H. Freeland an OON provider on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard  hard appliance, full arch (D9944) 
provided on April 20, 2023. 
 
You asked the Plan to pay for the occlusal guard. You say that this claim should be filed under medical and not 
dental. The Plan denied your request. The Plan says there is no coverage for D9944 - occlusal guard-hard 
appliance, full arch. 
 
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 the occlusal 
guard  hard appliance, full arch (D9944) provided on April 20, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 100-day supply of Autolet lancing devices. 
 
You asked the Plan to pre-approve a 100-day supply of Autolet lancing devices. The Plan denied your request. 
The Plan says the requested amount is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that more than one spring powered device (code 
A4258) per 6 months is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a 100-day supply of Autolet lancing devices have not been met. Specifically, the case file shows 
correspondence with the Plan on September 13, 2023, where you confirmed that the request was being made 
for a quantity of 100 Autolet lancing devices and not for lancets. Therefore, we decided that the Plan does not 
have to pre-approve a 100-day supply of Autolet lancing devices.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified adjunctive procedures (D9999) provided on 
April 11, 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 
unspecified adjunctive procedures (D9999) provided on April 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 1, 
2021, to May 26, 2021. 
 
You asked the Plan to pay for the SNF care. You say that the claim was filed within the appropriate timeframe. 
The Plan denied your request. The Plan says the claim was filed late without good cause. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the SNF care was not filed until May 12, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 1, 2021, to May 26, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional filling (D2393) provided on May 4, 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 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 May 4, 2023. Therefore, 
we decided that the Plan does not have to pay for an additional filling (D2393) provided on May 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 13, 
2023, through June 15, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
  
 
 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the procedure provided is currently approved as an ambulatory procedure. There was no 
documentation submitted to support that the enrollee required a greater than two midnight stay, such as peri-  
or post-operative complications. The review has determined that the record did not show that at the time of the 
inpatient admission the admitting physician reasonably expected that the enrollees necessary hospital care 
(including earlier emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from June 13, 2023, through June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307, G0480, and 83789 provided on 
March 28, 2023.  
You asked the Plan to pay for procedure codes 80307, G0480, and 83789. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem. 
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. 
 
Medicare rules also say that providers performing validity testing on urine specimens utilized for drug testing 
should not separately bill the validity testing. We find that the testing described by 83789 is not separately 
payable. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 80307, G0480, and 
83789 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 80307, 
G0480, and 83789 provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 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 $1,250 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 May 18, 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 May 
30, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were told you needed teeth extracted and 
other dental work done so the x-rays were 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 the Plan paid for a panoramic radiographic image (D0330) on October 21, 2021; therefore, your benefit 
for the requested item or service was exhausted on the date of service of October 21, 2021. Therefore, we 
decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 30, 
2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the requested sensor should be covered. 
The Plan denied your request. The Plan says that the product does not meet the criteria.  
 
The Plan must follow 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 the requested device. Our physician 
reviewer found that the enrollee has type 1 diabetes. The enrollee uses an insulin pump and is at risk for low 
blood sugars. Therefore, the request is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. The Freestyle Libre 3 is now a covered 
device, as it has been assigned the covered code of E2103 as of June 15, 2023. Based on this information, we 
decided that Medicare rules for coverage of the requested device have been met. Therefore, we decided that the 
Plan has to pre-approve a continuous glucose monitor.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on June 5, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is a non-Medicare approved/certified 
freestanding emergency facility. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit. have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on June 5, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on June 26, 2022. 
 You asked the Plan to pay for the hospital services. You say that records have been submitted to show medical 
necessity. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital services provided on June 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), x-ray exam of the lumbosacral spine 
(72100), and the x-ray exam of the cervical spine (72040) provided on May 8, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99202), x-ray exam of the lumbosacral spine (72100), 
and the x-ray exam of the cervical spine (72040) provided on May 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided from 
April 27, 2023, through June 1, 2023. 
 
 
  
 
 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acupuncture services are not payable as 
they were not rendered on the basis of a covered diagnosis. Additionally, the acupuncture services were not 
provided by a supervised acupuncturist.  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered on the basis of a diagnosis for chronic low back pain. Additionally, the acupuncture services were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810, 
97811) provided from April 27, 2023, through June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingival flap procedure (D4240) provided on October 19, 
2022, to November 9, 2022. 
 
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 a gingival 
flap procedure (D4240) provided on October 19, 2022, to November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental service. You say that your previous denture broke and they are 
unable to get fixed. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a complete lower denture (D5120) on May 27, 2021; therefore, your benefit for the 
requested item or service was exhausted on the date of service of May 27, 2021. Therefore, we decided that the 
Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on January 13, 2023. 
 You asked the Plan to pay for the ambulance services. You say that you state that the hospice service was 
revoked prior to the ambulance services. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance services provided on January 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services without transport provided on May 18, 
2023. 
 
You asked the Plan to pay for the ambulance services. You say that the services were a medical emergency. 
The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and 
without a transport there is no payable service. 
 
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 May 18, 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 ambulance services without transport provided on 
May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92004) 
provided on April 11, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92004). You say that you are 
appealing the $30 copayment you were 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 each Medicare-covered examination. 
 
You have been asked to pay a $30 copayment for a medical eye examination (92004). This item/service falls 
within the each Medicare-covered examination 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 a medical eye examination (92004) provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions, gingival irrigation with a medicinal 
agent, and unspecified periodontal procedures (D4999, D1330, D4921) provided on May 22, 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 oral 
hygiene instructions, gingival irrigation with a medicinal agent, and unspecified periodontal procedures 
(D4999, D1330, D4921) provided on May 22, 2023.