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

 
We decided that the Plan does not have to pay for dental services provided on March 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. 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 dental services provided on March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 and 88311 billed for date of service 
July 7, 2022. 
 You asked the Plan to pay for procedure code(s) 88305 and 88311. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says these codes are included in the 
facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305 and 88311. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88305 and 
88311. Based on this information, we decided that Medicare rules for coverage of procedure codes 88305 and 
88311 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88305 and 88311 billed for date of service July 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. You say that you are concerned due to family history, and you 
are a pre-diabetic with high cholesterol. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary and when the enrollee meets at least one criteria of the LCD listed in the Medicare rules 
section..  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found Medicare does not cover CT coronary 
calcium scoring unless there is a calculate lifetime risk of ASCVD of 5-19.9%. No such calculation is present 
in the records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis. 
 
You asked the Plan to pre-approve the CT scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 the CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of prostate cancer 
with a non-palpable tumor found. Gleason 3+3. No neurovascular invasion. Per LCD guidelines the request for 
CT abdomen and pelvis is not necessary since there has been no information provided to indicate a risk of 
spread beyond the prostate gland. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on 
February 23, 2023. We also decided that the Plan does not have to waive the copayment for a medical eye 
examination (92014). 
 
You asked the Plan to pay for a determination of refractive state (92015). You also asked the Plan to waive the 
copayment for a medical eye examination (92014). You say that your wife had the exact same services done, 
but was fully covered and your services were not. The Plan denied your request. The Plan says a determination 
of refractive state (92015) is only covered when done as part of a routine eye examination. The Plan also says 
that the cost sharing was charged correctly for a medical eye examination (92014). 
 
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 determination of refractive state when it is part of a routine examination. 
 
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 
copayment for a medical eye examination (92014).  
 
We looked at the file and the Plan's rules. The Plan rules say that they cover routine (refractive) eye 
examinations. Medical or diagnostic refractions are not a covered benefit. The record shows this was a 
medical/diagnostic determination of refractive state (92015).  
 
You have been asked to pay a $40 copayment for a medical eye examination (92014). This item/service falls 
within the specialist office visit 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. 
 
Based on this information, we decided that the Plan's rules for coverage of a determination of refractive state 
(92015) and a medical eye examination have not been met. Therefore, we decided that the Plan does not have 
to pay for a determination of refractive state (92015) provided on February 23, 2023. We have also decided that 
the Plan does not have to waive the copayment for a determination of refractive state (92015).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve the occlusal guard  hard appliance. You say that you need another night 
guard. You also say that you received one through insurance two years ago and had to buy the second one out-
of-pocket due to the maximum allowed amount per pay period. The Plan denied your request. The Plan says 
your benefit for the occlusal guard  hard appliance 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 occlusal guard  hard appliance was exhausted on date of service June 30, 2021. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch 
(D9944).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 
 
You asked the Plan to pre-approve the Freestyle Libre 3. You say that your physician said that you need the 
specific CGM because you need to be monitored constantly by phone. The Plan denied your request. The Plan 
says the requested CGM is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that your partial denture does not fit anymore, 
and you need a replacement. 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 June 14, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on May 6, 2022. 
 
You asked the Plan to pay for the compression stockings. 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 they do not 
meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that your denture was broken and needs to be 
replaced. 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 February 19, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the criteria for coverage have not been met. 
 
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 the CT scan. Our reviewer says that the 
service is medically necessary. Our physician reviewer found NCD criteria for CT coronary calcium screening 
will cover such a test in an asymptomatic patient if the lifetime risk of acute coronary vascular disease event is 
calculated to be between 5-19%.  According to the records this patient's risk is 16% which qualifies for the 
requested CT coronary calcium scoring test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the heart.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and electrocardiogram (EKG) provided on 
January 19, 2023. 
 You asked the Plan to pay for the office visit and EKG. You say that the enrollee's hospice was revoked prior 
to the date of service. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an office visit and electrocardiogram (EKG) provided on 
January 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from August 5, 2022, 
to August 17, 2022 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you already met your maximum out-
of-pocket for the year. 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 $230 
copayment each day for days 1 to 7 and a $0 copayment for additional days for Medicare-covered hospital care.  
 
 You have been asked to pay $1,610 for an IRF stay ($230 per day x 7 days = $1,610). Your maximum out-of-
pocket of $3,900 was not met at the time this claim processed. This item/service falls within the inpatient 
hospital 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 IRF stay provided 
from August 5, 2022, to August 17, 2022
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on March 28, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that the records provided support the 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 skilled nursing facility 
provided on March 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
performed at a specialists office provided on March 24, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI) performed at a 
specialists office. You say that you were not aware of the amount of your copayment and are unable to afford 
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 $180 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $180 copayment for a magnetic resonance imaging (MRI) performed at a 
specialists office. This item/service falls within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a magnetic resonance imaging (MRI) performed at a specialists 
office provided on March 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on February 6, 2023, to 
February 7, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
received on February 6, 2023, to February 7, 2023.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 1, 
2023, to February 4, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the Plan's website was not clear about 
the copayment for the facility and the enrollee was unaware of the limited number of days there would be a 
zero 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 $0 
copayment per day for days 1 to 20, a $172 copayment per day for days 21 to 55, and $0 copayment per day for 
days 56 to 100 for SNF care.  
 You have been asked to pay $516 for a SNF stay ($172 per day x 3 days = $516). This item/service falls within 
the SNF 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 a SNF stay provided from 
February 1, 2023, to February 4, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on January 30, 2023. 
 You asked the Plan to pay for the genetic testing. You say that the claim should be processed as in-network. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for genetic testing provided on January 30, 2023.