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

 
We decided that the Plan does not have to pay for gingival irrigation (D4921), oral hygiene instructions 
(D1330), localized delivery of antimicrobial agents (D4381) and periodontal scaling and root planing (D4341) 
provided on June 16, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says gingival irrigation, oral hygiene instructions, and localized delivery of antimicrobial 
agents are not covered services. Periodontal scaling and root planing is a covered benefit but for dental 
conditions that have two or more possible treatments, the Plan will cover the lowest cost treatment if it is 
proven to provide satisfactory results. If the member chooses to receive a higher cost treatment, the member 
will be responsible to pay the difference.  
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 gingival 
irrigation (D4921), oral hygiene instructions (D1330), and localized delivery of antimicrobial agents (D4381). 
Periodontal scaling and root planing (D4341) will be paid for at the lower rate provided on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue regeneration (D4266), therapeutic parenteral drugs 
(D9610), and additional sedation (D9243) provided on March 8, 2023. 
 
You asked the Plan to pay for D4266, D9610, and D9243. You say that all of these services are medically 
necessary. 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 tissue 
regeneration (D4266), therapeutic parenteral drugs (D9610), and additional sedation (D9243) provided on 
March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit, and the blood draw provided 
by an out-of-network provider on May 4, 2023. 
 
You asked the Plan to waive the deductible for the office visit, and the blood draw. You say that this provider is 
in-network. 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 a $1,250 deductible which applies to all services besides all in-network 
covered services, all supplemental benefits, and emergency services. 
 
 
 
 
 
 You have been asked to pay a $8.57 deductible for the blood draw. This item or service you asked the Plan to 
waive the deductible for falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. You have also been asked to pay a $213.52 deductible for the office visit. This item or service you 
asked the Plan to waive the deductible for falls within the physician/practitioner services, including doctor's 
office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $1,250 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies, 
and physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation 
that had not been met at the time the office visit, and the blood draw were provided on May 4, 2023. Therefore, 
we decided that the Plan does not have to waive the deductible for the office visit, and the blood draw provided 
by an out-of-network provider on May 4, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on July 
12, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. 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 a home or residence visit 
for the evaluation provided on July 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
June 1, 2023, and billed with codes 87481, 87798, 87653 and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on June 1, 2023, and billed with codes 87481, 87798, 87653 and 87801.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid examination for both ears (92591) provided on 
April 11, 2023. 
 
You asked the Plan to pay for a hearing aid examination for both ears (92591). You say that you do not 
understand why the provider performed the services if you were not covered for them. The Plan denied your 
request. The Plan says these services are not covered under your medical benefit. The Plan also says they do 
offer supplemental hearing aid coverage, but you did not purchase this supplemental benefit Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you purchase a supplemental Plan coverage.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid examination for both ears (92591) have not been met. Therefore, we decided that the 
Plan does not have to pay for a hearing aid examination for both ears (92591) provided on April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the incontinence supplies provided on April 18, 2023. 
 
You asked the Plan to pay for the incontinence supplies. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that they did not receive the 
reimbursement claim within the 120-day deadline date of the purchased items. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also 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 
reimbursement documentation must be postmarked within 120 days of the purchase/service date. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The file shows that you purchased incontinence supplies on April 18, 2023. The 
120-day deadline date to send your receipts would have been August 16, 2023. The file shows that the claim 
was not received until August 28, 2023; however, the Plan contract bases the deadline date on when the claim 
was postmarked. The Plan has not confirmed the claim was not postmarked within the 120-day deadline date as 
the postmarked date and received date can be different dates. Therefore, we decided that the Plan has to pay for 
the incontinence supplies provided on April 18, 2023.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on June 21, 2023. 
 
You asked the Plan to pay for ambulance response and treatment, no transport (A0998). You say that due to 
fatigue and weakness from chemotherapy, you were unable to get back to bed. You also say that it took three 
paramedics to help you get into the bed. The Plan denied your request. The Plan says since there was no 
transport, ambulance charges are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
  The ambulance company did not provide transport services on June 21, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on June 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes (A5500), and inserts (A5512). 
 
You asked the Plan to pre-approve the diabetic shoes and inserts. You say that this is a medical necessity. The 
Plan denied your request. The Plan says the Statement of Certifying Physician for Therapeutic Shoes did not 
demonstrate evidence of all the required criteria, as noted in Section 2 of the Medical Necessity form. 
 
The Plan must follow Medicare rules. Medicare rules say that health plans must ensure that services are 
provided when medically necessary..  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diabetic shoes and inserts have not been met. Therefore, we decided that the Plan does not have 
to pre-approve diabetic shoes (A5500), and inserts (A5512).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for in ear binaural hearing aids provided on February 13, 
2023.  
 
You asked the Plan to reimburse for in ear binaural hearing aids. You say that you cannot afford $5,000. You 
also say you never used the $500 benefit and want to know if you can get more than $500. The Plan denied 
your request. The Plan says the member has already met the coverage limit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for up 
to $500 towards the hearing aids once every three years. 
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of in ear binaural hearing aids have not been met. Therefore, we decided that the Plan does not have 
to reimburse for in ear binaural hearing aids provided on February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for comprehensive dental services provided 
on June 1, 2023. 
 
You asked the Plan to waive the coinsurance for comprehensive dental services. You say that you do not feel 
like you should owe anything for these services. 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 50% 
coinsurance for dental services/comprehensive services.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for comprehensive dental services. This 
item/service falls within the dental services/comprehensive 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 coinsurance for comprehensive dental services provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on January 24, 
2023, to February 18, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for chiropractic manipulative treatment. The Plan denied your request. The Plan says 
that chiropractic manipulative treatment is available in network. 
 
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 chiropractic manipulative treatment provided on 
January 24, 2023, to February 18, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on July 20, 2023, and billed with codes 87798 and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
testing provided on July 20, 2023, and billed with codes 87798 and 87481.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dentures (D5110/D5120) provided on March 13, 2023. 
 
You asked the Plan to pay for dentures. You say that you believe the dentures should be covered. The Plan 
denied your request. The Plan says the rendered 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 dentures 
(D5110/D5120) provided on March 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custodial care services provided from April 4, 2023, to 
April 25, 2023. 
 
You asked the Plan to pay for the custodial care services. You say that you meet the criteria for homebound and 
the services were medically necessary. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because custodial care is not covered. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the custodial care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the 
custodial care services provided from April 4, 2023, to April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) and 
a guided tissue regeneration (D7956) provided on June 23, 2023. 
 
You asked the Plan to pay for D7953 and D7956. You say that this dental work was an absolute necessity. 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 bone 
replacement graft for ridge preservation (D7953) and a guided tissue regeneration (D7956) provided on June 
23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the brain. 
 
You asked the Plan to pre-approve an MRI of the brain. The Plan denied your request. The Plan says an MRI of 
the brain is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the brain. Our reviewer says 
that an MRI of the brain is not medically necessary. Our physician reviewer found the MRI of the brain does 
not appear to be indicated and there are no neurological symptoms or deficits. Also, the positron emission 
tomography (PET) scan is ordered for disease monitoring. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the brain.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on July 17, 2023, and billed with codes 87150, 87798, 87481, 87640, and 87653. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
testing provided on July 17, 2023, and billed with codes 87150, 87798, 87481, 87640, and 87653.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two intraorifice barriers (D3911) provided on March 16, 
2023. 
 
You asked the Plan to pay for D3911. You say that you believe the Plan should pay for this. The Plan denied 
your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for two 
intraorifice barriers (D3911) provided on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an astigmatism correcting function of intraocular lens 
(V2787) and supplies and materials (except spectacles), provided by the physician or other qualified health care 
professional (99070) provided on May 5, 2023. 
 
You asked the Plan to pay for an astigmatism correcting function of intraocular lens (V2787) and supplies and 
materials (except spectacles), provided by the physician or other qualified health care professional (99070). 
You say that you were not guided regarding the payment required by the medical institution regarding 
reimbursement. The Plan denied your request. The Plan says the services are not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
 
  While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for an astigmatism 
correcting function of intraocular lens (V2787) and supplies and materials (except spectacles), provided by the 
physician or other qualified health care professional (99070) provided on May 5, 2023.