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

 
We decided that the Plan does not have to pay for eye refraction services (92015) provided June 19, 2020. 
 
You asked the Plan to pay for the vision services. You say that you got eyeglasses. The person at the counter 
said it would be paid by the plan and you did not have to pay any money. The Plan denied your request. The 
Plan says this service is not covered as the refraction was performed as a part of a medical vision check 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed as part of a routine eye exam. 
 
 
 
 
 
 
We looked at the file and the Plan's rules. Eye refractions are only covered when performed by a participating 
provider and performed as part of a routine eye exam. The records show this was a medical vision check. Based 
on this information, we decided that the Plan's rules for coverage of the vision services have not been met. 
Therefore, we decided that the Plan does not have to pay for eye refraction services (92015) provided June 19, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for extracapsular cataract removal provided 
on February 2, 2020, and March 4, 2020. 
 
You asked the Plan to waive the copayments for extracapsular cataract removal. You say that you were not 
informed of the charges ahead of time and cannot afford them due to COVID-19. The Plan denied your request. 
The Plan says the claims were processed correctly, and you are being charged the correct amount. 
 
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 $325 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You received extracapsular cataract removal on February 2, 2020, and March 4, 2020. Extracapsular cataract 
removal is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $325 per each 
surgery. The total amount you owe is: $650.  
 
You have been asked to pay the total copayment amount of $650 for extracapsular cataract removal. 
Extracapsular cataract removal falls within the outpatient surgery and other medical services provided at 
hospital outpatient facilities and ambulatory surgical centers 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 copayments for extracapsular cataract removal provided on February 2, 2020, and March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower 
denture (D5120) provided on March 18, 2020. 
 
You asked the Plan to pay for the dental items. You say that you were advised by a plan representative that 
there were no in network dentists within 1 hour of you. You say that you were advised you were in the 
timeframe for dentures to be covered 100%. You say that you were advised you would be reimbursed fully for 
the dentures. You also say that since you have not been reimbursed, this has put a financial burden on you. The 
Plan denied your request. The Plan says the provider in this case is not an in network dentist. The Plan says 
there are in network dentists that could have provided the dentures. The Plan also says dental items you receive 
out of network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dentures are not among those covered 
under this benefit when you receive them out of network. Therefore, we decided that the Plan does not have to 
pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided on March 18, 
2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 testing provided on April 14, 2020. 
 
You asked the Plan to pay for genetic test. You say that the enrollee's treating physician ordered this testing to 
determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. The 
Plan says that the denial of payment for this testing is correct, because the enrollee did not meet the medical 
criteria for coverage of this testing. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
This testing was ordered by an in-network physician. The file does not show that the plan provided notice that 
genetic test would not be covered. Under Medicare rules, this means genetic test is considered approved by the 
plan. Therefore, we decided that the Plan has to pay for Guardant360 testing provided on April 14, 2020.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical necessity for an out-of-network provider. 
 
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 
a referral to an out-of-network physical therapist.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says 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 Prolia. Our reviewer says that the 
enrollee has not met the step therapy requirements for coverage of the requested drug. Our physician reviewer 
found that the Plan requires a trial of drug Zoledronic acid before it will approve the requested drug. In this 
case, there is no documentation provided indicating that the enrollee tried and failed the required drug. There is 
no documentation provided indicating that the Plan?s required drug(s) would likely be less effective and/or 
likely have adverse effects for the 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3230). 
 
You asked the Plan to pre-approve foot orthotics. You say that the orthopedic footwear is medically necessary. 
The Plan denied your request. The Plan says the orthopedic footwear is not covered. 
 
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 (L3230).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation, intraoral x-ray and 
panoramic x-ray provided on June 2, 2020 and the extraction and unspecified preventive procedure provided on 
June 4, 2020. 
 
You asked the Plan to pay more for the limited oral evaluation, intraoral x-ray, panoramic x-ray, extraction and 
unspecified preventive procedure. You say that the handbook specified $2,000 coverage in-network and out-of-
network. The Plan denied your request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay the 
allowed amount for your covered dental services from an out-of-network provider. You are responsible for any 
amount greater than the payment made by the Plan. The Plan did not make any payment for the unspecified 
preventive procedure because it is not listed as a covered benefit.  
 
 
 
 
 
 
 
 
Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation, intraoral x-ray 
and panoramic x-ray provided on June 2, 2020 and the extraction and unspecified preventive procedure 
provided on June 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member's current needs are being met at the current facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to return to being independent. The Plan 
denied your request. The Plan says your needs do not require close physician supervision, or an 
interdisciplinary team approach for care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our physician reviewer found 
that you were admitted to the acute hospital for a lumbar fusion. Your medical problems are stable. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The 
medical record supports a need for physical and occupational therapy, but it does not support a need for an 
intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the psychiatric diagnostic evaluation 
(90791) and the group psychotherapy (G0410) provided from February 19, 2020, through March 16, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 
copayment for outpatient mental health care provided at an outpatient hospital.  
 
You have been asked to pay $600 ($50 copayment x 12 sessions) for the outpatient mental health care provided 
at an outpatient hospital. 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 adjust the copayment for the psychiatric diagnostic 
evaluation (90791) and the group psychotherapy (G0410) provided from February 19, 2020, through March 16, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the established patient office or other outpatient visit 
(99213) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the established patient office or other outpatient visit. You say that you 
would like to continue care with an OON provider you saw in the past. The Plan denied your request. The Plan 
says the requested service is available within the network with multiple other equally qualified providers. 
 
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 established patient office or other outpatient visit (99213) to be provided by an out of network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care provider office visit (99213) 
on July 22, 2020. 
 
You asked the Plan to waive the copayment for a primary care provider office visit. You say that you did not 
ask for other services beyond your annual physical exam. The Plan denied your request. The Plan says the 
correct copayment was applied. 
 
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 $15 
copayment for each visit for a primary care provider office visit. Your contract also says that there is no 
coinsurance, copayment, or deductible for the annual physical exam but when services other than preventive 
are performed, the cost-share (copayment/coinsurance) associated with the other service will apply. 
 
You have been asked to pay a $15 copayment for a primary care provider office visit. A primary care provider 
office visit falls within the "Physician/Practitioner services, including doctor?s office visits" benefit category. 
The case record documents that services beyond your annual physical exam were provided. 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 primary care provider office visit (99213) on July 22, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous Ferumoxytol. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee was recently hospitalized 
for renal failure and anemia. The Plan denied your request. The Plan says the documentation does not show 
that the enrollee has iron deficiency anemia, or has a documented failure of Infed, Venofer, or Ferrlecit. 
 
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 the requested services. Our physician 
reviewer found that The Plan requires a trial Infed, Venofer, or Ferrlecit, and a diagnosis of iron deficiency 
anemia before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the Plan's required drugs are likely to be 
less effective, or likely have adverse effects for the 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve intravenous Ferumoxytol.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need these services to reach your baseline to go 
home. The Plan denied your request. The Plan says that you can safely receive the services you need in other 
settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for abdominal pain and sepsis. 
You had surgery to drain a retroperitoneal abscess. Your medical problems are stable. There are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. You 
do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF care. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgently needed services provided on April 
6, 2020. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the 
charges because the visit was due to you having COVID-19. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
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 $30 
copayment for urgently needed services.  
 
You have been asked to pay a $30 copayment for urgently needed services. Urgently needed services falls 
within the urgently needed 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 
urgently needed services provided on April 6, 2020.