Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 27, 2023, by an out-of-
network (OON) provider.  
 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information about this, see Section 2 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 27, 2023, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an overdenture  complete mandibular (D5865), add metal 
substructure to acrylic full denture (per arch) (D5876), precision attachment, by report (D5862), and 
overdenture  complete maxillary (D5863) provided on March 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were under the impression you were under 
a PPO plan and you do not agree with the denial. 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 an overdenture  complete mandibular (D5865), add metal substructure to acrylic full denture (per 
arch) (D5876), precision attachment, by report (D5862), and overdenture  complete maxillary (D5863) 
provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on April 11, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
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 a home visit provided on 
April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
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 February 24, 2021. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve dental 
services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on April 05, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that the enrollee is in a facility and the facility 
should have obtained the prior 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 a nursing facility visit 
provided on April 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on April 06, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that this patient is in a facility, and you depend 
upon the facility staff for any verification or prior 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 a nursing facility visit 
provided on April 06, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the enrollee is blind and would benefit from a CGM. 
The Plan denied your request. The Plan says the enrollee does not meet the medical criteria for a CGM. 
 
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. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for D0350 x3, D5820, D1330 and D4999 x4 provided on April 
17, 2023, to April 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you went for fillings but then the provider 
began requesting computed tomography (CT) scans, additional x-rays, and tests. You say that you feel you 
were taken advantage of and should not have to pay for the billed services. The Plan denied your request. The 
Plan says your benefits for the requested services have already been exhausted and/or 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. This benefit includes the 
requested D0350 but is limited to one per 36 floating months and D5820 but is limited to one per 60 floating 
months. This benefit includes an annual maximum of $1,250. After the annual maximum is exhausted, any 
remaining charges are your responsibility. D1330 and D4999 are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received one covered 2D oral/facial photographic images obtained intraorally or extra orally 
(D0350) on April 17, 2023. Therefore, this benefit has been exhausted. Therefore, we decided the Plan does not 
have to pay for 2D oral/facial photographic images obtained intraorally or extra orally (D0350) x3 provided on 
April 17, 2023. 
 
The record shows the Plan paid $1,032 on date of service April 17, 2023, and $218 on date of service April 18, 
2023 ($1,032 + $218 = $1,250). After the annual maximum is exhausted, any remaining charges are your 
responsibility. Therefore, this benefit has been exhausted. Therefore, we decided the Plan does not have to pay 
more for the interim partial denture (including retentive/clasping materials, rests, and teeth), (mandibular) 
(D5820) provided on April 17, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D1330 and D4999 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral 
hygiene instructions (D1330), and unspecified periodontal procedure, by report (D4999) x4 provided on April 
17, 2023, to April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the office visit provided on March 22, 
2023. 
 
You asked the Plan to waive the cost sharing for the office visit. You say that this was an annual physical and 
should not have any cost sharing. 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. Your 
contract with the Plan says that there is an $800 deductible which applies to doctor and other health care 
provider services. Your contract with the Plan also says that you must pay 10% coinsurance for office visits. The records show that other health concerns were addressed outside the scope of an annual physical exam, and 
the office visit coinsurance was applied correctly. You have been asked to pay $32, which is less than the 
standard 10% coinsurance for the office visit. You have also been asked to pay $231.67 towards the deductible. 
The item or service you asked the Plan to waive the cost sharing for falls within the doctor and other health 
care provider services benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is an $800 deductible which applies to doctor and other health care provider services. This 
cost sharing is a contractual obligation that had not been met at the time the office visit was received on March 
22, 2023. You have been asked to pay a total of $263.67 ($32 coinsurance + $231.67 deductible = $263.67). 
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 cost sharing for the office visit provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visit. You say that you want a second opinion for this issue. The 
Plan denied your request. The Plan says there are other network providers who can provide a second opinion. 
 
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 office visit to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure 
(CPAP) supplies provided on February 11, 2023, to April 11, 2023. 
 
You asked the Plan to waive the coinsurance for continuous positive airway pressure (CPAP) supplies. You say 
that you think that you are being billed incorrectly. 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 Medicare-covered durable medical equipment. 
 
You have been asked to pay 20% coinsurance for continuous positive airway pressure (CPAP) supplies. This 
item/service falls within the in-network Medicare-covered durable medical equipment 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 
$108.96 ($544.87 allowed amount x 20% = $108.96 rounded down). Therefore, we decided that the Plan does 
not have to waive the coinsurance for continuous positive airway pressure (CPAP) supplies provided on 
February 11, 2023, to April 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a myocardial perfusion imaging, the 
diagnostic agents, and a regadenoson injection provided on January 1, 2023. 
 
You asked the Plan to waive the cost share for a myocardial perfusion imaging, the diagnostic agents, and an 
injection. You say that you do not have a coinsurance with your Plan. 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 $175 
copayment for outpatient diagnostic tests and therapeutic services and supplies. Your contract with the Plan 
also clearly says that you must pay 20% coinsurance for Medicare Part B drugs. 
 
You have been asked to pay a $175 copayment for a myocardial perfusion imaging. 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.  
 
You have also been asked to pay 20% coinsurance of the allowed amount for the Medicare Part B drugs. This 
item/service falls within the Medicare Part B prescription drugs benefit category. 
 
Date of Service Code Allowed Amount 20% Coinsurance 
January 10, 2023 A9500 $1,450 $290 
January 10, 2023 Q9969 $22 $4.40 
January 10, 2023 J2785 $2,469 $493.80 
 
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 cost share for a myocardial perfusion imaging, the diagnostic agents, and a 
regadenoson injection provided on January 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided on May 15, 2023, to May 
16, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the provider did not tell you they were 
out-of-network. 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.  
 
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. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 the dental services provided on May 15, 
2023, to May 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital stay provided on September 24, 2020, to 
September 26, 2020. 
 
You asked the Plan to pay for inpatient hospital stay. You say that you are requesting reconsideration for the 
services 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 inpatient hospital stay 
provided on September 24, 2020, to September 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of non-tunneled central venous catheter (36556) 
provided on August 15, 2022. 
 
You asked the Plan to pay for the insertion of non-tunneled central venous catheter (36556). You say that the 
attached medical records support code 36556 and the claim should be reprocessed to pay this code. The Plan 
denied your request. The Plan says procedure code 36556 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
  In this case, the CPT Code Manual definition of code 36556 is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the insertion of non-tunneled central venous catheter 
(36556). Our reviewer says that the documentation does not support the procedure code billed. Our reviewer 
found the procedure report does not include sufficient documentation to confirm an insertion of non-tunneled 
centrally inserted central venous catheter. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the insertion of non-tunneled central venous catheter (36556) have not been 
met. Therefore, we decided that the Plan does not have to pay for the insertion of non-tunneled central venous 
catheter (36556) provided on August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, and related services provided on May 08, 
2023. 
 
You asked the Plan to pay for an office visit, and related services. 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 an office visit, and 
related services provided on May 08, 2023.