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

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 
You asked the Plan to pre-approve the compression stockings. You say that the items should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6531.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve Gel-One. You say that you have tried multiple treatments and you are 
progressively getting worse to the point that it is impacting your day-to-day function. The Plan denied your 
request. The Plan says that the step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-One. Our reviewer says that Gel-
One is not medically necessary. Our physician reviewer found that you have not tried and failed the Plan's 
required drugs Euflexxa or Synvisc-One. Also, there is no indication that the Plan's required drugs would likely 
be less effective or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular and maxillary complete dentures (D5110, 
D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 April 27, 2021. 
Therefore, we decided that the Plan does not have to pre-approve mandibular and maxillary complete dentures 
(D5110, D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endodontic treatment (D3999) to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the dental service. You say that you cannot wait a long time for an 
appointment in-network because you are experiencing pain. The Plan denied your request. The Plan says dental 
services from an out-of-network provider are not covered by your supplemental benefits. Also, there are 
multiple in-network provider available in your service area. 
 
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 item or service is 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 the 
endodontic treatment (D3999) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), the intraoral 
complete series of radiographic images (D0210), and the panoramic radiographic image (D0330) provided on 
April 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you went to a new dentist and the x-rays found 
that you need 2 repairs. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 the Plan paid for a comprehensive oral evaluation (D0150) and a panoramic radiographic image (D0330) 
on March 25, 2021; therefore, your benefit for the requested items or services was exhausted on the date of 
service of March 25, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150), the intraoral complete series of radiographic images (D0210), and the panoramic 
radiographic image (D0330) provided on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
#6. 
 
You asked the Plan to pre-approve the dental services. You say that the previous procedure did not work and 
you would like the Plan to cover it again. The Plan denied your request. The Plan says your benefit for the 
requested items or services 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 the Plan paid for the core buildup (D2950) for tooth #6 on May 13, 2021, and paid for the crown 
(D2740) for tooth #6 on June 10, 2021; therefore, your benefit for the requested items or services was 
exhausted on the dates of services of May 13, 2021, and June 10, 2021. Therefore, we decided that the Plan 
does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and the panoramic 
film (D0330) provided by an out-of-network provider on April 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told by the provider that they were in-
network. 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. Also, there are multiple in-network providers 
available in your service area. 
 
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 a comprehensive oral evaluation (D0150) and the panoramic film (D0330) provided by an out-of-
network provider on April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the incisional biopsy 
(D7286) provided on May 10, 2022.  
 
You asked the Plan to pay for the dental services. You say that the dental services were medically necessary, 
and you need them to be paid so they can be sent to the secondary insurance for whatever cost share remains. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
Plan only covers Medicare-covered dental services only. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) and the incisional biopsy (D7286) provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 the dental services on March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000).  
 
You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle kit sensor. 
 
You asked the Plan to pre-approve the FreeStyle kit sensor. You say that the medical records support the 
medical necessity for the CGM.  The Plan denied your request. The Plan says a CGM is not covered under 
Medicare if the member is not on insulin or does not have documentation of recurrent problematic 
hypoglycemia. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 FreeStyle kit sensor. Our reviewer 
says that the FreeStyle kit sensor is not medically necessary. Our physician reviewer found coverage criteria for 
the CGM require insulin use or low blood glucose sugar. The enrollee is not taking insulin and is not having 
low blood glucose sugar that we are told of. The enrollee is also on a diabetes mellitus medication that usually 
does not cause low blood glucose sugar. Coverage criteria for a CGM are not met. We are not told why finger 
stick monitoring is not sufficient for this enrollee. 
 
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 FreeStyle kit sensor have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle kit sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral and bitewing x-ray (D0230, D0270) provided on 
December 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 March 16, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral and bitewing x-ray (D0230, D0270) 
provided on December 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 29, 2022, 
to October 28, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the home health services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the rendering and referring providers are both OON 
providers and there was no approved authorization. Also, the services rendered were not urgent or emergent. 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 the home health services provided from September 
29, 2022, to October 28, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 16, 2022, 
to January 12, 2023. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 16, 2022. The NOA was not received by the Plan until March 
17, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from December 16, 2022, to January 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 22, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance service helped you to get up and waited to see if you were okay. You also say that you were not 
transported to the hospital. The Plan denied your request. The Plan says these services are not a covered 
benefit.  
 
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 April 22, 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 the ambulance response and treatment with no 
transport provided on April 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified adjunctive procedure, by report (D9999). 
 
You asked the Plan to pre-approve the unspecified adjunctive procedure, by report. You say that you are 
requesting to get a new procedure called dental wave. You also say that this is a root canal treatment that 
promotes pain-free and fast healing. The Plan denied your request. The Plan says this service is not covered 
under your dental benefit package. 
 
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 pre-approve an 
unspecified adjunctive procedure, by report (D9999).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from April 7, 2023, to 
April 30, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the cost share 
applied for your SNF stay. 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 for days 1 to 20 and a $196 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $588 for a SNF stay ($196 per day x 3 days = $588). 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 
April 7, 2023, to April 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 21, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the Plan paid 
nothing towards the claim even though the service was authorized. 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 $250 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $250 copayment for a computed tomography (CT) scan. 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. The total you owe is 103.35, which is less than the standard copayment for a CT 
scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography 
(CT) scan provided on March 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chemotherapy treatment provided from 
January 10, 2023, to January 31, 2023. 
 
You asked the Plan to waive the copayment for chemotherapy treatment. You say that you do not agree with 
the cost applied for your chemotherapy treatment. 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 each chemotherapy drug and the administration of that drug.  
 
You have been asked to pay $3,795 coinsurance for chemotherapy treatment. This total is less than the standard 
copayment for chemotherapy drugs and the administration of the drugs because your maximum out-of-pocket 
was met with the processing of this claim. 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. 
Therefore, we decided that the Plan does not have to waive the copayment for chemotherapy treatment 
provided from January 10, 2023, to January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) provided on January 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were informed this was a covered 
procedure and you should not be held responsible for payment. The Plan denied your request. The Plan says 
this service is not a covered benefit under your dental plan. 
 
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 the core 
buildup (D2950) provided on January 5, 2023.