Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the extracapsular cataract removal with insertion of 
intraocular lens prosthesis services coded 66984 provided on November 13, 2019. 
 
You asked the Plan to pay for the extracapsular cataract removal with insertion of intraocular lens prosthesis 
services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the services billed are not supported by the documentation. 
 
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 66984 is extracapsular cataract removal with insertion of 
intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or 
phacoemulsification); without endoscopic cyclophotocoagulation. 
 
We find that CPT code 66984 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of procedure note in detail for the billed date of service. Based on this 
information, we decided that Medicare rules for coverage of the extracapsular cataract removal with insertion 
of intraocular lens prosthesis services have not been met. Therefore, we decided that the Plan does not have to 
pay for the extracapsular cataract removal with insertion of intraocular lens prosthesis services coded 66984 
provided on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services and the laboratory services provided 
on August 31, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit services and the laboratory services. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 has network providers 
available who can provide 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 office visit services and the laboratory services 
provided on August 31, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presbyopia correct function implantable lens received on 
August 25, 2020. 
 
You asked the Plan to pay for the presbyopia correct function implantable lens. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a 
covered benefit. 
 
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 presbyopia correcting 
feature of an IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia correct function 
implantable lens received on August 25, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency services provided. 
 
You asked the Plan to waive the copayments for the emergency services. You say that the services were post 
follow up after a procedure so you would like the Plan to waive the copayments. The Plan denied your request. 
The Plan says you were charged the copayments 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 $120 
copayment for Emergency Care.  
 
You have been asked to pay a $120 copayment for each of the emergency services. The emergency services fall 
within the Emergency 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 copayments for emergency 
services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on January 
21, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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. 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 out of network services 
provided to the enrollee on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevator function (E2300) and expandable 
controller (E2377, E2313, E2311) for a powered mobility device. 
 
You asked the Plan to pre-approve the seat elevator function and expandable controller. You say that these 
accessories are medically necessary. The Plan denied your request. The Plan says rules for coverage are not 
met. 
 
The Plan follows Medicare rules. Medicare rules say that seat elevator features are not covered. Expandable 
controllers are only covered when medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the seat elevator function and 
expandable controller. Our reviewer says that the expandable controller is not medically necessary. Our 
physician reviewer found the patient has sufficient strength in the upper extremities and functional ability to 
operate any power options through their own individual switches. Power seat elevation features are not 
covered. 
  
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 seat elevator function and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a seat elevator function (E2300) and 
expandable controller (E2377, E2313, E2311) for a powered mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2377, 
E2311, E2313) for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the expandable harness (E2313), the (E2311) electronic connection, and the (E2377) 
expandable controller are not medically necessary. The documentation does not reveal that the enrollee needs 
an expandable controller to operate other types of proportional input devices (e.g., mini-proportional or 
compact joysticks, touchpads, chin control, head control, etc.), non-proportional input devices (e.g., sip and 
puff, head array, etc.), or to operate 3 or more powered seating actuators through the drive control. 
 
The documentation does not reveal the enrollee needs the expandable controller to operate a separate display 
(i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or 
computer through the chair's drive control), or for an attendant control. The enrollee has sufficient strength in 
the upper extremities and functional ability to operate any power options through their own individual 
switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2377, E2311, E2313) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ambien for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee is stable on this medication. The Plan 
denied your request. The Plan says that this is not covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ambien for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429, A0425) provided February 26, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary and 
the claim should be paid. The Plan denied your request. The Plan says the allowable amount has already been 
paid by the auto insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
EOB from the primary payer. As the secondary insurer, the Plan cannot be held responsible for the ambulance 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for ambulance services (A0429, A0425) provided February 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for three panoramic x-rays (D0330 x3), eight surgical accesses to an implant body (D6011 x8), and three bone grafts at time of implant placement (D6104 x3).

You asked the Plan to pay for the panoramic x-rays, surgical accesses to an implant body, and bone grafts. You say that you cannot wear lower dentures because there is not enough bone for a lower denture to conform to, even with adhesive. The Plan denied your request. The Plan says the surgical access to an implant body and bone graft at time of implant placement are not covered under your benefit package. The Plan also says that the panoramic x-ray exceeds the maximum count allowed per period.

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, surgical access to an implant body (D6011) and bone graft at time of implant placement (D6104) are not among those covered under this benefit. The contract also clearly states that panoramic x-ray (D0330) is limited to one procedure every three plan years. The record shows that you received a panoramic x-ray (D0330) on June 8, 2020, and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for three panoramic x-rays (D0330 x3), eight surgical accesses to an implant body (D6011 x8), and three bone grafts at time of implant placement (D6104 x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0637) provided on June 29, 2020. 
 
You asked the Plan to pay for a back brace. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is not proof of delivery for this item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. This documentation 
has not been submitted. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for a back brace 
(L0637) provided on June 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health services 
 
You asked the Plan to pre-approve the services provided. The Plan denied your request. The Plan says your 
condition has improved, and you are no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued services from January 16, 2021, forward was requested. 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 services provided. Our physician reviewer found that active treatment 
was not taking place. It did not appear that the services are reasonably expected or medically necessary to 
improve your condition or for the purpose of diagnosis. Based upon review the records provided, you could be 
treated in a lesser restrictive setting. You were being cooperative and compliant while not showing any acute 
threats to safety. You were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression. 
 
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 services provided have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued inpatient mental health services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on November 29, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to you by an out-of-network provider on 
November 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say you're in pain and that this is medically necessary. 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the diagnostic imaging of the optic eye provided 
on September 15, 2020. 
 
You asked the Plan to waive the copay for these services. You say that this service was necessary for a correct 
diagnosis. The Plan denied your request. The Plan says that this charge is your responsibility. 
 
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 $90 
copay for each covered diagnostic procedure or test at a network doctor's office.  
 
You have been asked to pay a $934.90 copay for these services. These services fall within the covered 
diagnostic procedure or test at a network doctor's office benefit category. This means that you have been asked 
to pay less than 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 copay for the diagnostic imaging of the optic eye provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the premium cataract surgery provided on June 8, 2020. 
 
You asked the Plan to pay for the premium cataract surgery. You say that this surgery was medically necessary 
and recommended by your providers. The Plan denied your request. The Plan says Medicare does not cover the 
premium cataract surgery additional services, including laser cataract surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pay for the premium cataract surgery. Our reviewer 
says that you were approved for standard cataract surgery. Our physician reviewer found the record does not 
show that premium cataract surgery was medically reasonable and necessary. 
 
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 premium cataract surgery have not been met. In addition, the record 
indicates that you signed and advanced beneficiary notice of non-coverage. Therefore, we decided that the Plan 
does not have to pay for the premium cataract surgery provided on June 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling provided on October 6, 2020. 
 
You asked the Plan to pay for the dental service. You say that your tooth had broken in half. You say that it 
was very painful. You say that you could not eat or drink anything hot or cold. You also say that you 
considered this to be an emergency. The Plan denied your request. The Plan says the filling is beyond the scope 
of the preventive dental care. The Plan also says that fillings are not among the services that are listed in the 
plan contract as covered non-routine dental care. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service you are asking the Plan to 
pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly 
supporting your 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 the filling provided on October 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan, pelvis; without contrast material (CPT Code 
72192) for the enrollee. 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your 
request. The Plan says they need to see results of an x-ray taken after the member's symptoms started or 
changed that failed to provide all of the details needed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT scan. Our physician reviewer 
found the enrollee reports progressive atraumatic pain in the right hip. The enrollee noted low back pain, 
radiating to the hip as well as swelling in the leg and foot ongoing since Summer 2020. The examination was 
very limited as the visit was conducted virtually. The enrollee has a known diagnosis of osteoporosis. The 
imaging was order to evaluate for an occult fracture. There is no documentation of any active range of motion 
assessment or plain film imaging to assess for fracture. Medical necessity cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CT scan, pelvis; without contrast material (CPT Code 72192) for the enrollee.