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

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and intraoral radiographic 
images (D0220) provided by an out-of-network provider on November 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received a letter saying the dental services 
were denied so you want to appeal the denied services. 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 a periodic oral evaluation (D0120) and intraoral radiographic images (D0220) provided by an out-of-
network provider on November 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
November 03, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you would like to appeal 
the copayment for this service. 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 $230 
copayment for one-way ambulance services. 
 
You have been asked to pay a $230 copayment for the ambulance services. This item/service falls within the 
one-way ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance services provided on November 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the pain management office visit provided 
on January 05, 2023. 
 
You asked the Plan to waive the copayment for the pain management office visit. You say that you were told 
the copayment for a specialist would not go up for 2023. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for outpatient therapeutic services, including pain management. 
 
You have been asked to pay a $35 copayment for the pain management office visit. This item/service falls 
within the outpatient therapeutic services, including pain management 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 pain management office visit provided on January 05, 2023.
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 January 03, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that the services 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 an office visit and 
related services provided on January 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implant, custom fabricated abutment, and 
abutment supported porcelain/ceramic crown (D6058, D6010, D6057). 
 
You asked the Plan to pre-approve 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 pre-approve 
endosteal implant, custom fabricated abutment, and abutment supported porcelain/ceramic crown (D6058, 
D6010, D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic and retainer crown (D6245, D6740). 
 
You asked the Plan to pre-approve 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 you do 
not meet the clinical requirements to be approved. 
 
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 a 
pontic and retainer crown (D6245, D6740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on December 20, 2022. 
 
You asked the Plan to pay for lab testing. You say that you say that the requesting provider is responsiblity to 
gain authorization. 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 
December 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urinary catheter anchoring device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve urinary catheter anchoring device. You say that the services should be 
covered. The Plan denied your request. The Plan says this is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
urinary catheter anchoring device to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the intraoral 
radiographic image (D0220) provided on December 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were advised to go to the endodontics to get 
your toot cleaned out instead of seeing a surgeon. 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 that the Plan paid for an evaluation on December 8, 2022; therefore, your benefit for the limited oral 
evaluation was exhausted on the date of service of December 8, 2022. The record also shows that the Plan paid 
for an intraoral radiographic image on January 29, 2022; therefore, your benefit for the intraoral radiographic 
image was exhausted on the date of service of January 29, 2022. Therefore, we decided that the Plan does not 
have to pay for a limited oral evaluation (D0140) and the intraoral radiographic image (D0220) provided on 
December 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits/consultation and Magnetic-Resonance-
Guided Focused Ultrasound Surgery (MRgFUS) with an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits/consultation and MRgFUS. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that MRgFUS unilateral thalamotomy is considered 
medically reasonable and necessary in patients who meet certain criteria. 
 
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 office visits/consultation and MRgFUS. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the records 
provided for review did not demonstrate that all of the requirements of the LCD for coverage of this service 
had been met. The enrollee is not a candidate for DBS and has no contraindications to DBS. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of office visits/consultation and MRgFUS have not been met. Therefore, we 
decided that the Plan does not have to pre-approve office visits/consultation and Magnetic-Resonance-Guided 
Focused Ultrasound Surgery (MRgFUS) with an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on January 23, 
2023. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial of payment for the 
service you received. The Plan denied your request. The Plan says this service is not covered under your 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. Oral hygiene instructions 
(D1330) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D1330 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral hygiene 
instructions (D1330) provided on January 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 10, 2023, to January 15, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford the 
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 $275 
copayment per day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 for each Medicare-covered 
hospital stay.  
 
 You have been asked to pay a $275 copayment per day, for days 1 to 5 of the inpatient hospital stay. You have 
been asked to pay a total of $1,375 ($275 copayment x 5 days = $1,375). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital care 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 inpatient hospital stay provided from January 10, 2023, to 
January 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure provided on 
February 02, 2022. 
 
You asked the Plan to pay for unlisted molecular pathology procedure. You say that the services 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 unlisted molecular 
pathology procedure provided on February 02, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided by an out-of-network 
provider from February 18, 2021, to March 19, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you submitted the claim to just 
update the correct code form the generic code. The Plan denied your request. The Plan says the corrected claim 
was not submitted within the 1 year of the initial process date. 
 
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 home health care services was not filed until March 26, 2021. 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 home health care services provided by an out-of-network 
provider from February 18, 2021, to March 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power mobility device to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve power mobility device. You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for 
more information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-
of-network provider (a provider who is not part of the plans network) will not be covered. This means that the 
enrollee will have to pay the provider in full for the services furnished. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
power mobility device to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on 
February 02, 2023. 
 
You asked the Plan to reduce the copayment for the specialist office visit. You say that you had paid $30 for a 
specialist office visit in the past. 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 $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 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 reduce the copayment for the specialist office visit provided on February 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care provider office visit and 
EKG provided on January 4, 2023. 
 
You asked the Plan to waive the copayment for the office visit and EKG. You say that this should be 
considered your yearly physical exam and have no 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 $10 
copayment for primary care provider office visits. Your contract with the Plan also clearly says that you must 
pay a $20 copayment for outpatient diagnostic tests.  
 
The record shows this claim was approved and you are responsible for the cost share amount. You have been 
asked to pay a $10 copayment for the office visit. This item/service falls within the physician/practitioner 
services benefit category. You have also been asked to pay $14.70, which is less than the standard $20 
copayment for the EKG. This item/service falls within the outpatient diagnostic tests and therapeutic services 
benefit category. You have been asked to pay a total of $24.70 ($10 copayment + $14.70 copayment = $24.70). 
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 primary care provider office visit and EKG provided on 
January 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek aviva plus test strips. 
 
You asked the Plan to pre-approve the test strips. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says only the preferred brand products listed in the 
EOC are covered. 
 
  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 test strips. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek aviva plus test 
strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home-delivered meals (S5170). 
 
You asked the Plan to pre-approve home-delivered meals. You say that the physician requested home-delivered 
meals upon discharge from the hospital because it is a needed service. You also say that it was your belief that 
this and other benefits were assured in the enrollee's outlined coverage benefits, and you would like due 
diligence provided by approving all that the enrollee is due to receive. The Plan denied your request. The Plan 
says this request for Medicare home-delivered meals does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that home delivery of meals may be offered as a 
supplemental benefit if the services are needed due to an illness, consistent with established medical treatment 
of the illness, and offered for a short duration. 
 
We looked at the file and Medicare rules. Specifically, the record shows that the enrollee was not admitted with 
the qualifying diagnosis of congestive heart failure. The enrollee was admitted/discharged for the diagnosis of 
delirium. Based on this information, we decided that Medicare rules for coverage of home delivered meals 
have not been met. Therefore, we decided that the Plan does not have to pre-approve home-delivered meals 
(S5170).  
 
Your complaint about the dissatisfying experience and poor level of care and services the enrollee and your 
family have received thus far 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.