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

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), the intraoral 
radiographic images (D0220), and the extraction (D7140) for tooth #21 provided by an out-of-network provider 
on December 23, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were not told that the provider was 
not in-network, and you believe you do not owe anything. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. Also, the proper cost share was applied. It was confirmed that the enrollee 
never contacted the Plan prior to receiving the dental services to verify network status. 
 
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. For the oral evaluation the total amount billed was $85 and the total allowed amount was $50 leaving a 
difference of $35 ($85 billed - $50 allowed). The total amount billed for the intraoral images was $34 and the 
total allowed amount was $15 leaving a difference of $19 ($34 billed - $15 allowed). The total amount billed 
for the extractions was $206 and the total allowed amount was $75 leaving a difference of $131 ($206 billed - 
$75 allowed). The total coinsurance amount for the extraction was $37.50 ($75 allowed x 50% coinsurance). 
The total difference amount for the dental services was $185 ($35 difference + $19 difference + $131 
difference). You have been asked to pay the difference between the out-of-network providers charges and the 
Plans payment. You have also been asked to pay a 37.50 coinsurance for the extraction. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to pay more for a limited oral evaluation (D0140), the intraoral radiographic images (D0220), 
and the extraction (D7140) for tooth #21 provided by an out-of-network provider on December 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided out of the country on November 21, 
2022. 
 
You asked the Plan to pay for out of the country services. You say that this should be covered. The Plan denied 
your request. The Plan says dental services provided outside the country are not covered. 
 
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 dental 
services provided out of the country on November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator provided on June 22, 
2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that the transition in the 
authorization process delayed this claim, so the Plan should allow an exception to the filing time frame. The 
Plan denied your request. The Plan says you did not timely file the claim for this item. 
 
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 automatic external defibrillator was not filed until November 7, 2022. 
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 automatic external defibrillator provided on 
June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pin retention (D2951) provided on January 19, 2023. 
 
You asked the Plan to pay for pin retention. You say that you believe this should be covered by the Plan. The 
Plan denied your request. The Plan says the rendered dental service is not a covered 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pin 
retention (D2951) provided on January 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan with coronary calcium score. 
 
You asked the Plan to pre-approve a CT scan with coronary calcium score. You say that you do not have any 
major health issues except high cholesterol and some heart issues. You say that your cardiologist recommended 
that you have a CT scan done for the calcium building in your arteries. The Plan denied your request. The Plan 
says a CT scan with coronary calcium score is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan with coronary calcium score. 
Our reviewer says that a CT scan with coronary calcium score is not medically necessary. Our physician 
reviewer found that a coronary CT calcium score is used to assist decision making about starting a Statin for 
primary prevention of atherosclerotic events in individuals with a moderate 10-year atherosclerotic event risk 
who are seeking a strong indication to start medical treatment. There is no evidence of this in the notes 
provided. 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 CT scan with coronary calcium score have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a CT scan with coronary calcium score.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bifocals and the miscellaneous vision service provided on 
November 15, 2022. 
 
You asked the Plan to pay for the bifocals and the miscellaneous vision service. You say that you should be 
reimbursed for the eyeglasses. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
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 covers these services when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the bifocals and the miscellaneous vision service 
have not been met. Therefore, we decided that the Plan does not have to pay for the bifocals and the 
miscellaneous vision service provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on January 27, 2023. 
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care 
provided on January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020) and single vision lenses (V2100) 
provided on December 19, 2022. 
 
You asked the Plan to pay for the frames and lenses. You say that you did not know about the eligible date. 
You also say that the eligible date was not stated by your insurance plan nor the provider you saw for the 
glasses. The Plan denied your request. The Plan says you were not yet eligible to receive new eyeglasses using 
your plan's rolling calendar year vision allowance on this date of service. 
 
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 covers a $175 vision allowance for routine contact lenses or eyewear every year, and this 
benefit is administered on a rolling calendar year since your last date of service. 
 
 We looked at the file and the Plan's rules. The record shows that you last received eyewear using your plan's 
vision allowance on December 20, 2021, and your benefit had been exhausted. Based on this information, we 
decided that the Plan's rules for coverage of the frames and lenses have not been met. Therefore, we decided 
that the Plan does not have to pay for the frames (V2020) and single vision lenses (V2100) provided on 
December 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 24, 2022, 
to March 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that because this is a crossover claim, 
you do not believe the admit date on the NOA and the claim have to match. The Plan denied your request. The 
Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 24, 2022, to 
March 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory service provided on 
November 22, 2022. 
 
You asked the Plan to waive the copayment for the laboratory service. You say that the blood work is a part of 
your annual physical. 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 $5 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $5 copayment for the laboratory service. This item/service falls within the 
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. The record shows annual wellness exams do not 
include laboratory services. Therefore, we decided that the Plan does not have to waive the copayment for the 
laboratory service provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lens, the progressive lens, the anti-
reflective coating, the tint, and the frames provided on January 18, 2023.  
You asked the Plan to pay for the vision items. You say that you were told that the provider was in-network. 
The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 covers these services when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision items have not been met. Therefore, we 
decided that the Plan does not have to pay for the polycarbonate lens, the progressive lens, the anti-reflective 
coating, the tint, and the frames provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), anti-reflective coating (V2750), vision 
item or service (V2799), and progressive lens (V2781) provided on October 17, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the frames, anti-reflective coating, vision item or service, and progressive lens. 
You say that you would like a one-time exception for coverage to be made, as you had to max out a credit card 
to purchase these glasses. You also say that you cannot live without your glasses. The Plan denied your request. 
The Plan says the treating provider is OON with your plan, and there is no coverage when services are rendered 
by a non-participating provider. 
 
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 covers these services when they are rendered by an in-network provider. 
 
 We looked at the file and the Plan's rules. The record shows that you received this eyewear from an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the frames, anti-reflective 
coating, vision item or service, and progressive lens have not been met. Therefore, we decided that the Plan 
does not have to pay for the frames (V2020), anti-reflective coating (V2750), vision item or service (V2799), 
and progressive lens (V2781) provided on October 17, 2022, by an out-of-network (OON) provider.
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 enrollee is having a difficult time managing their 
blood sugar levels and the CGM will help them. 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. Specifically, the records indicates that the enrollee does not use 
insulin and states the enrollee does not have hypoglycemia. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) and scanning 
computerized ophthalmic diagnostic imaging (92134)  
You asked the Plan to pay for the determination of refractive state and ophthalmic diagnostic imaging. You say 
that this was a diabetic retinopathy screening visit, and you should not have any liability. The Plan denied your 
request. The Plan says the determination of refractive state is a non-covered benefit. 
 
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. 
 
We looked at the file and the Plan's rules. Determination of refractive state is not listed as a covered benefit. 
Based on this information, we decided that the Plan's rules for coverage of the determination of refractive state 
have not been met. 
 
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 $40 
copay for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $37 copay for the scanning computerized ophthalmic diagnostic imaging, which 
is less than the standard $40 copayment for Medicare-covered diagnostic radiological services performed in a 
professional office or a freestanding radiological clinic. This service falls within the 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 pay for the determination 
of refractive state (92015) and scanning computerized ophthalmic diagnostic imaging (92134)
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the high-index lenses (V2783) provided on January 26, 2023 by an in-
network provider. 
 
You asked the Plan to pay for the high-index lenses. You say that you feel this is medically required for you to 
have. You also say that the prism lenses help treat your double vision. The Plan denied your request. The Plan 
says that high-index lenses are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules 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, premiums and cost-sharing, and 
any other conditions associated with receipt or use of benefits. Medicare rules also say that a contract provider 
is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan 
unless notice is provided that the services will not be covered. 
 
 
 
 
 
 The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not supported their denial of payment in this case. A schedule to 
support that there was not a dollar value for the provided high-index lenses was not provided for this case. The 
Evidence of Coverage language is not clear regarding limitations for eyewear benefit, as it does not specifically 
state that high-index lenses are not covered. The record also shows that you went to a participating provider, 
and could have reasonably believed there would be coverage for these lenses. No evidence of notification of 
non-coverage is shown. It is the burden of the Plan to substantiate their denial with evidence. In this case, the 
denial has not been substantiated. Therefore, we decided that the Plan has to pay for the high-index lenses 
(V2783) provided on January 26, 2023 by an in-network provider.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on February 06, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that the supplies should not require 
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 the wound care supplies 
provided on February 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 03, 2022. 
 
You asked the Plan to pay for an office visit. 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 provided 
on December 03, 2022.