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

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), and a partial 
mandibular denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat well with your current 
dentures. 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 3, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), and a partial 
mandibular denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110). 
 
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 January 28, 2020. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional routine transportation trips. 
 
You asked the Plan to pre-approve 10 additional routine transportation trips. You say that you live in the 
country and the city bus does not come to your area. The Plan denied your request. The Plan says you have 
exhausted your routine transportation benefit for 2023. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 10 additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87150, 87481, 87641, 87653, 87798, and 
87801) provided on April 4, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798, and 87801. 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 covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87150, 87481, 87641, 87653, 87798, and 87801 are not supported in the medical 
record. Specifically, a panel was performed and there is a more appropriate singular code for the services. 
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 panel testing (87150, 87481, 87641, 87653, 
87798, and 87801) provided on April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dermatology consultation to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve a dermatology consultation. You say that you are requesting reconsideration 
of the denied services. The Plan denied your request. The Plan says the services were not approved. 
 
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 
a dermatology consultation to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination provided on June 23, 2023. 
 
You asked the Plan to pay for radiologic examination. 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 radiologic examination 
provided on June 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry Services provided on July 13, 2023. 
 
You asked the Plan to pay for podiatry Services. You say that the 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 podiatry Services 
provided on July 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
 
 You asked the Plan to pre-approve the additional miles. You say that you are requesting additional miles so you 
can get to your chiropractor because you have scoliosis. You also say that you need to see the chiropractor for 
your back because it affects your walk and your quality of life overall. The Plan denied your request. The Plan 
says the service is a covered benefit, but the request will exceed the benefit limits set in the agreement for 
routine transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 miles per one-way per trip.  
 
We looked at your request, the records in the case file, and the rules. You are requesting an additional 11 miles 
for a total of 61 miles and your benefit only allows 50 miles. Based on this information, we decided that you 
have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that 
the Plan does not have to pre-approve additional routine transportation miles.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on December 16, 2022. 
 
You asked the Plan to pay for a new patient office visit. You say that the enrollee was unaware that they 
needed a referral. 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 a new patient office visit 
provided on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 25, 2023, to May 19, 
2023. 
 
You asked the Plan to pay for psychotherapy. 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 psychotherapy provided 
on January 25, 2023, to May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on July 12, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service July 11, 2023.  
  
 
 
 
 
Specifically, the Plans contract states that two topical applications of fluoride varnish are covered per year. 
You previously received these services on June 1, 2023 and July 11, 2023 accordingly, which were paid for by 
the Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, we decided that the 
Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on July 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ambulance ride provided on 
June 20, 2023. 
 
You asked the Plan to waive the copayment for an in-network ambulance ride. You say that you feel you 
should not have to pay for this as you had terrible treatment and could not get in to see your doctor on time. 
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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for an in-network ambulance ride. This item/service falls within 
the 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 an in-
network ambulance ride provided on June 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an osteogenesis stimulator provided on 
August 08, 2022. 
 
You asked the Plan to waive the coinsurance for an osteogenesis stimulator. You say that you were not told that 
you would have a cost share. 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 20% 
coinsurance for in-network durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for an osteogenesis stimulator. This item/service falls within the 
in-network durable medical equipment (DME) and related 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 total you owe is $714 ($3,570.02 allowed 
amount x 20% = $714). Therefore, we decided that the Plan does not have to waive the coinsurance for an 
osteogenesis stimulator provided on August 08, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on March 19, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. 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 laboratory service 
provided on March 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 11, 2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you have not had to pay for this 
service 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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for an ultrasound. 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. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided on July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 04, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. 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 office visit provided 
on May 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 01, 2023. 
 
You asked the Plan to pay for an office visit. You say that you believe that you were in-network for the 
members plan. 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 June 01, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7.  
You asked the Plan to pre-approve a Dexcom G7. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
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. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G7 have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Dexcom G7.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lumbar spine magnetic resonance imaging 
(MRI) provided on July 14, 2023. 
 
You asked the Plan to waive the copayment for lumbar spine magnetic resonance imaging (MRI). You say that 
you do not agree with 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 $200 
copayment for advanced radiology services including MRI. 
 
You have been asked to pay a $200 copayment for lumbar spine magnetic resonance imaging (MRI). This 
item/service falls within the advanced radiology services including MRI 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. However, since the allowed amount is 
less than the standard copayment, you only owe $195.98. Therefore, we decided that the Plan does not have to 
waive the copayment for lumbar spine magnetic resonance imaging (MRI) provided on July 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 13, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with 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 $300 
copayment for ambulance services. 
 
You have been asked to pay a $300 copayment for ambulance services. This item/service falls within the 
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 ambulance services 
provided on May 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oxygen equipment to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve the oxygen equipment. You say that you need the appeal approved to cover 
your oxygen so you can receive the care you need. 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 of 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. 
 
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 
the oxygen equipment to be provided by an out-of-network (OON) provider.