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

 
We decided that the Plan does not have to pay for the sleep apnea oral appliance provided on September 23, 
2020 billed with two units of code E0486. 
 
You asked the Plan to pay for the oral appliance as billed. You say that this should be paid at the allowable 
amount as all coverage criteria are met. The Plan denied your request. The Plan says billing with two units of 
this code is not appropriate. The claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code E0486 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the oral appliance as billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the sleep apnea oral appliance provided on 
September 23, 2020 billed with two units of code E0486.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to further reimburse you for the eye exam (92014) and assessment for 
prescription eye wear (92015) provided on August 17, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to further reimburse you for the eye exam and assessment for prescription eye wear. You 
say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The 
Plan says the claim processed correctly according to the Plan's benefit. 
 
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 with a $75 allowance when they are rendered by an OON provider. 
The enrollee is responsible for any amount charged over $75. 
 
We looked at the file and the Plan's rules. The file indicates that the Plan reimbursed you for $75 and only 
charged you the remaining difference based on their contractual language. Based on this information, we 
decided that the Plan's rules for coverage of the eye exam and assessment for prescription eye wear have 
processed correctly. Therefore, we decided that the Plan does not have to further reimburse you for the eye 
exam (92014) and assessment for prescription eye wear (92015) provided on August 17, 2020, by an out-of-
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi (J9173). 
 
You asked the Plan to pre-approve Imfinzi. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Imfinzi. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found as the enrollee has not had reimaging and 
it is unclear if stage IV, imfinzi is not 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 Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi (J9173).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of corneal structure and measurement (76514) 
and diagnostic imaging of optic nerve of eye (92133) provided on July 29, 2020, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the ultrasound of corneal structure and measurement and diagnostic imaging of 
optic nerve of eye. You say that these services were medically necessary. The Plan denied your request. The 
Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been 
correctly denied. 
 
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 ultrasound of corneal structure and 
measurement (76514) and diagnostic imaging of optic nerve of eye (92133) provided on July 29, 2020, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) and hospital discharge day 
management services (99239) provided on January 3, 2020, through January 8, 2020. 
 
You asked the Plan to pay for the critical care and hospital discharge day management services. You say that 
you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 
the documentation does not include the amount of time rendering these services. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
The CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. 
 
We find that CPT code 99291 and 99239 is not supported in the record. Specifically, the documentation 
submitted does not indicate the amount of time rendering these services. Based on this information, we decided 
that Medicare rules for coverage of the critical care and hospital discharge day management services have not 
been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) and 
hospital discharge day management services (99239) provided on January 3, 2020, through January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home visual field assessment (Foresee Home). 
 
You asked the Plan to pre-approve Foresee Home. You say that this service is medically necessary and covered 
by Medicare. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this is experimental/investigational. 
 
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 Foresee Home. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has bilateral nonexudative macular degeneration. The standard of care in this 
situation is oral based antioxidant vitamins, home monitoring with Amsler grid, and frequent follow-up 
examinations. The Foresee Home monitoring system has been evaluated and validated by prospective analysis 
and has been shown to be a safe and effective system for exudative macular degermation surveillance for high-
risk individuals in a relatively limited study. Overall, the Foresee Home system may be more effective, but 
only a single study of short duration exists to compare the efficacy. there is no evidence that the Foresee Home 
system improves disease outcomes, or that it would be superior for treatment of the enrollee's intermediate non-
exudative macular degeneration as compared with standard treatments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Foresee Home have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home visual field assessment (Foresee Home).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you asked the dental assistant if you owed anything for these services and were told no. You also say 
that you cannot afford to pay for these services. The Plan denied your request. The Plan says these services 
exceed the maximum 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, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation and complete series of intraoral x-
rays on April 6, 2018, and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays 
(D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic resonance (e.g., proton) imaging (MRI), 
spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; 
thoracic (72157). 
 
You asked the Plan to pre-approve an MRI. You say that the enrollee needs an MRI. The Plan denied your 
request. The Plan says a repeat scan is not medically necessary because there is no evidence it will reasonably 
impact care. 
 
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 a repeat MRI. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found there is no clear indication why the 
patient needs an MRI of the upper back. Most recent office notes document improvement in the lower back and 
neck pain. The enrollee has had a negative bone scan and cat scan in the past. The service is not reasonable and 
medically 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 an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Magnetic resonance (e.g., proton) imaging (MRI), spinal canal and contents, without contrast 
material, followed by contrast material(s) and further sequences; thoracic (72157).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, complete series of intraoral x-
rays, and prophylaxis provided on September 1, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, complete series of intraoral x-rays, and prophylaxis. 
You say that you told the representative that you wanted to retain the same dentist who you have had for more 
than 20 years. You also say that you do not wish to change dentists, and want coverage for at least cleanings 
and checkups. The Plan denied your request. The Plan says these services were rendered by an OON provider. 
The Plan also says that no benefits are available for procedures performed by OON providers. 
 
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 requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation, complete series of intraoral x-rays, and prophylaxis provided on September 1, 2020 by an OON 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the complete upper 
denture (D5110), and the complete lower denture (D5120) provided on August 12, 2020. 
 
You asked the Plan to pay for the dental services. You say that your Evidence of Coverage states that you are 
covered 70% for dentures. You say that you have had your current dentures for 17 years. You say that they are 
cracked and cannot be fixed. You say that page 95 of your Evidence of Coverage states that dentures are 
covered every 5 years. You also say that it was never explained to you that you do not have this coverage. The 
Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan 
also says that dentures are not listed as covered items. 
 
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 requested items or services are not 
among those covered under this benefit. The record shows that you were referring to your 2019 dental benefits 
when you were referencing page 95. The 2020 Evidence of Coverage does not list dentures as covered. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the complete 
upper denture (D5110), and the complete lower denture (D5120) provided on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 14, 
2020. 
 
You asked the Plan to pay for the dental services. You say that you changed dentists. You say that you and the 
dentist office bone called the Plan multiple times to verify that they were in network. You say that network 
status and dental history was verified and an appointment was made as a result. The Plan denied your request. 
The Plan says 1 set of bitewing x-rays per plan year are covered. The Plan also says that the frequency limit has 
been exceeded. 
 
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 frequency limit of 1 set of bitewing 
x-rays per plan year has been exceeded. The record shows that the Plan paid for bitewing x-rays that you 
received on March 10, 2020. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays 
(D0274) provided on September 14, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you have 
reached your maximum potential at the SNF. 
 
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. 
 
Continued services beyond January 1, 2021 were 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 continued services. Our physician reviewer found that from a nursing perspective, you 
received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. 
Regarding rehab services, you were at a maximal assist to dependent level with functional mobility. You 
required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. 
You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or 
intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on March 13, 2020. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the dental provider has opted out of the 
Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services provided on March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that you would like reconsideration because there are 
many stairs in your home and it is difficult for you to make it up the stairs. The Plan denied your request. The 
Plan says this is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ride provided on September 
12, 2019. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you should only be 
responsible for a $65 copayment for the ambulance. You say you have already paid the $150 copayment. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $150 
copayment per trip, each way.  
 
You have been asked to pay a $150 copayment for the ambulance ride. The ambulance ride falls within the 
Ambulance services benefit category. The record shows you were refunded $65 for your overpayment to the 
hospital for the emergency room visit. Therefore, you are still responsible for the $150 copayment to the 
ambulance copayment for the ambulance ride. 
 
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 the ambulance ride provided on September 12, 2019.  
 
Please note that the Explanation of Benefits (EOB) issued to you for this claim contains inaccurate information 
regarding the allowed amount of the claim. Please contact the health plan to receive a corrected Explanation of 
Benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the arthrocentesis provided from July 30, 
2020, to August 13, 2020. 
 
You asked the Plan to waive the copayments for the arthrocentesis. You say that you believe that $750 in 
copayments for three 5-minute visits. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 $250 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $250 copayment for each of the arthrocentesis procedures. The arthrocentesis 
falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. The record shows that the arthrocentesis is considered a surgical procedure. 
 
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 the arthrocentesis provided from July 30, 2020, to August 
13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for external mobile cardiovascular telemetry 
provided on March 20, 2020. 
 
You asked the Plan to waive the deductible for external mobile cardiovascular telemetry. You say that there 
were some complications with the device and you cannot afford the charges. 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. Your 
contract with the Plan says that there is a $975 deductible for outpatient diagnostic tests and therapeutic 
services and supplies.  
 
You received external mobile cardiovascular telemetry on March 20, 2020. The record shows that you had only 
paid $41.70 toward the $975 deductible prior to receiving the services. Therefore, you are responsible to pay 
the total allowed amount of $772.80.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $975 deductible for outpatient diagnostic tests and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time external mobile 
cardiovascular telemetry was received on March 20, 2020. Therefore, we decided that the Plan does not have to 
waive the deductible for external mobile cardiovascular telemetry provided on March 20, 2020.