Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 2, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that per the medical records submitted 
payment is requested. The Plan denied your request. The Plan says the provider is not a plan contract provider 
and is not enrolled in Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on August 10, 2023. 
 
You asked the Plan to pay for an eye refraction. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says although you did not have the liability placed on you per the 
explanation of benefits (EOB), the EOC does state only one refraction with a routine eye exam will be covered. 
The Plan also says since this was claim was billed under your medical coverage, this was not a routine 
examination, and the refraction would not be covered. 
 
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 the eye refractions are a part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that eye refractions outside of the annual non-
Medicare covered routine eye examinations are not covered. Based on this information, we decided that the 
Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not 
have to pay for an eye refraction (92015) provided on August 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 24, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that per the medical records submitted 
payment is requested. The Plan denied your request. The Plan says the provider is not a plan contract provider 
and is not enrolled in Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
July 27, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239) provided on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional intraoral images (D0220 and D0230) provided on 
August 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that there was a limit on this 
service. 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 August 8, 2023. Therefore, we decided that the Plan does not have to pay for additional intraoral images (D0220 and D0230) 
provided on August 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on July 13, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted all the 
relevant documents, including proof of delivery and other supporting documents to fulfill your obligations. 
You also say that you request that the claim be reprocessed and paid. The Plan denied your request. The Plan 
says the provider is not enrolled in Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intermittent urinary catheter provided on June 19, 2023. 
 
You asked the Plan to pay for an intermittent urinary catheter. You say that this was medically necessary and 
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 intermittent urinary 
catheter provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 17, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration for the service 
provided. 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 August 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond of a crown (D2920 x 2) provided 
on June 7, 2023. 
 
You asked the Plan to pay for these dental 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 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, dental 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 the re-cement or 
re-bond of a crown (D2920) provided on June 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on June 29, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you would like the medical 
records to be reviewed for proof of delivery and for the claim to be reprocessed and paid. The Plan denied your 
request. The Plan says the provider is not a plan contract provider and is not enrolled in Medicare as a durable 
medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on June 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an injection for osteoporosis provided on 
August 24, 2023. 
 
You asked the Plan to reduce the coinsurance for an injection for osteoporosis. You say that this was just your 
normal injection that usually costs $250. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an injection for osteoporosis. This item/service falls within 
the Medicare Part B prescription drugs 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. You have been asked to pay a total coinsurance of $351.70. Therefore, we 
decided that the Plan does not have to reduce the coinsurance for an injection for osteoporosis provided on 
August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injections provided on August 15, 
2023. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you were advised that your 
copayment would be $325 a month. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the injections. This item/service falls within the Medicare 
Part B prescription drugs 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 $435.54 ($2,177.70 allowed amount x 20% = $435.54). Therefore, 
we decided that the Plan does not have to waive the coinsurance for the injections provided on August 15, 
2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy provided on August 
01, 2023, to September 13, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy. You say that the provider told you they 
were in-network but you cant help they billed with the individual provider. 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 $55 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $55 copayment for each physical therapy. This item/service falls within the 
outpatient rehabilitation 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. The total you owe is $550 ($55 copayment x 10 visits = $550). Therefore, we 
decided that the Plan does not have to waive the copayment for each physical therapy provided on August 01, 
2023, to September 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on 
August 30, 2023. 
 
You asked the Plan to waive the copayment for the electrocardiogram (EKG). You say that you are requesting 
reconsideration stating you dont understand why you should be charged the $14.08 when you paid the $20 co 
pay and did the EKG only because the doctor wanted you to do it. 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 the electrocardiogram (EKG). 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. However, since the allowed amount is less than the 
standard copayment, you only owe $14.08. Therefore, we decided that the Plan does not have to waive the 
copayment for the electrocardiogram (EKG) provided on August 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on January 25, 2023. 
 
You asked the Plan to pay for telehealth services. You say that this provider was the only provider available for 
telehealth services. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for telehealth services 
provided on January 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care telemedicine provided on March 02, 2023. 
 
You asked the Plan to pay for wound care telemedicine. 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 wound care telemedicine 
provided on March 02, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
July 18, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239) provided on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on June 10, 
2023, to June 27, 2023. 
 
You asked the Plan to pay for the skilled nursing facility (SNF) care. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients. 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 skilled nursing 
facility (SNF) care provided on June 10, 2023, to June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on July 28, 2023. 
 
You asked the Plan to pay for the outpatient visit. You say that you are requesting reconsideration for the 
service provided. 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 outpatient visit 
provided on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 26, 2023, billed with 
procedure codes A7030-NU-KK and A7035-NU-KK. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the practitioner services provided have 
been met. Specifically, no medical records have been provided for the date of service in question. Therefore, 
we decided that the Plan does not have to pay for practitioner services provided on June 26, 2023, billed with 
procedure codes A7030-NU-KK and A7035-NU-KK.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an abutment 
supported crown (D6058) provided on September 19, 2023. 
 
You asked the Plan to pay for dental implants. You say that you need this procedure done but you do not get a 
lot from social security every month to cover this. The Plan denied your request. The Plan says the denied 
dental services are not covered 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 custom 
fabricated abutment (D6057), and an abutment supported crown (D6058) provided on September 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wound care visit provided on July 07, 2023. 
 
You asked the Plan to pay for a wound care visit. You say that this was an out-of-area case that needs to 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). There are other providers available who are in-network, who are within the Medicare 
allowable distance from the patient's residence. Your office is not out-of-area as it is also within the Medicare 
allowable distance. Therefore, we decided that the Plan does not have to pay for a wound care visit provided on 
July 07, 2023.