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

 
We decided that the Plan does not have to pay for comprehensive medical exam (92004) progressive lens 
(V2781) lens, index > = 1.66 plastic or > = to 1.80 glass (V2783) and frames (V2020) provided December 18, 
2018. 
 
You asked the Plan to pay for the vision services. You say that you are appealing because the provider did not 
submit the claim to the plan in the time frame of the billing for the services rendered. The Plan denied your 
request. The Plan says reimbursement requests must be submitted within 12 months from the date you received 
the service. This claim was submitted more than 12 months after the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the vision services was not filed until December 20, 2019. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for comprehensive medical exam (92004) progressive lens (V2781) 
lens, index > = 1.66 plastic or > = to 1.80 glass (V2783) and frames (V2020) provided December 18, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) and each additional fabricated post 
(D2953) provided on November 25, 2019. 
 
You asked the Plan to pay for the core buildup (D2950) and each additional fabricated post (D2953). You say 
that you had no choice but to get your tooth repaired. You say that you have $1,000 of dental coverage per 
year. The Plan denied your request. The Plan says the services 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, 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) and each additional fabricated post (D2953) provided on November 25, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services 
rendered on February 4, 2020 to February 5, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the charges are overpriced since 
nothing was done. The Plan denied your request. The Plan says the copayment was applied 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 $90 
copayment for each Medicare-covered emergency room visit.  
 
Review of the file shows that you received ER services on February 4, 2020 to February 5, 2020. You have 
been asked to pay a $90 copayment for these services. These services fall within the Medicare-covered 
emergency room visit 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 the 
emergency room (ER) services rendered on February 4, 2020 to February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the refraction, the eye exam, the ophthalmic 
diagnostic imaging, and the ophthalmic diagnostic ultrasound on January 20, 2020. 
 
You asked the Plan to waive the deductible for the refraction, the eye exam, the ophthalmic diagnostic imaging, 
and the ophthalmic diagnostic ultrasound. You say that you were told by the Plan agent that you would not 
have to pay anything. 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. Your 
contract with the Plan says that there is a $198 deductible that applies towards all Medicare Part B services.  
 
The refraction and eye exam you asked the Plan to waive the deductible for falls within the Vision Care 
benefit category. The ophthalmic diagnostic imaging and the ophthalmic diagnostic ultrasound you asked the 
Plan to waive the deductible for falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category.  
 
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible that 
applies towards each in-network Medicare-covered exam and each Medicare-covered radiological diagnostic 
services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a 
radiology center or medical clinic). 
 
This cost sharing is a contractual obligation that had not been met at the time the refraction, the eye exam, the 
ophthalmic diagnostic imaging, and the ophthalmic diagnostic ultrasound were received on January 20, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for the refraction, the eye exam, the 
ophthalmic diagnostic imaging, and the ophthalmic diagnostic ultrasound provided on January 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 23, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 did not pre-approve the 
laboratory services. 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 laboratory services provided on May 23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 17, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on 
December 16, 2019. 
 
You asked the Plan to pay for the drug testing. 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. 
 
We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the 
documentation submitted did not include a valid physician order/lab requisition form or medical records signed 
by the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 
80307 and G0483 provided on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 2, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that the enrollee has a benefit of 1 every 36 
months. The Plan denied your request. The Plan says the x-ray is only available once every 36 months. 
 
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 also has a maximum benefit 
of one D0210, D0277 or D0330 per 36 months. The Plan paid for intraoral complete series x-ray (D0210) 
provided on June 7, 2019, which exhausted the benefit. Therefore, we decided that the Plan does not have to 
pay for the panoramic x-ray (D0330) provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services that you provided on January 21, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 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 physician's services that you provided on January 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $275 copayment charged for ambulance transport from 
one hospital to another on April 3, 2020. 
 
You asked the Plan to waive this copayment. You say that you were transferred from one hospital to another 
for Covid 19 testing. You do not believe you should have to pay this copayment. The Plan denied your request. 
The Plan says this service was covered by the Plan, minus your traditional contractual copayment. 
 
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 $275 
copayment for ambulance transport. You have been asked to pay the correct amount based on your contract 
with the Plan. It should also be noted that while unusual or non-traditional services related to Covid 19 are 
being covered by Medicare, the cost share for services such as ambulance transport are not being waved. The 
Plan covered this transport minus your copayment. 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 $275 
copayment charged for ambulance transport from one hospital to another on April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for waterproof tape (A4452) collagen based wound filler 
(A6010) sterile gauze (A6402) provided February 19, 2020. 
 
You asked the Plan to pay for the wound supplies. You say that you wish to appeal the denial of this claim, 
according to Medicare guidelines it was denied in error. The Plan denied your request. The Plan says when 
DME is furnished for use in a SNF during a noncovered stay the DME MAC's still shall not make separate 
payment for DME, the Part B DME benefit does not cover DME items that are furnished for use in SNF's. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wound supplies was used in a SNF or hospital. Therefore, we decided that the Plan does 
not have to pay for waterproof tape (A4452) collagen based wound filler (A6010) sterile gauze (A6402) 
provided February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-sterile gloves (A4927) provided December 25, 2019. 
 
You asked the Plan to pay for the non-sterile gloves. You say that you have wounds on your leg and your aide 
cannot change them without gloves. The Plan denied your request. The Plan says this item is not covered by 
Medicare. 
 
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 pay for the non-sterile gloves (A4927) provided December 25, 2019.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee was admitted to 
acute care on 8/17/20 after a syncopal episode and fall at home where she sustained a closed left tib/fib 
fracture. She underwent surgery while in the hospital. The hospital course has included pain control. The 
enrollee's hemodynamics are stable. The enrollee is non-toxic and afebrile. Functionally, she is 
minimal/moderate assist for functional activities of daily living and transfers.  
 
Records do not indicate that there are significant, or complex medical/nursing issues that could not be 
addressed at a lesser level of care.  Ongoing pain medication and other medication management, wound care, 
and daily therapy can be provided at a lesser level of care. In this case, the member is mostly moderate/minimal 
assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will 
allow for measurable gains to be attained within a reasonable, and predicted period.  An IRF intensity is not 
warranted. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive procedure provided on September 13, 2019. 
 
You asked the Plan to pay for the adjunctive procedure. You say that you submitted your claims on time. You 
say that these should be resolved. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, adjunctive procedure is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the adjunctive 
procedure provided on September 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Doxorubicin injections provided January 
31, 2019 to February 27, 2019. 
 
You asked the Plan to waive the coinsurance for the injections. You say that the coinsurance should be waived. 
The Plan denied your request. The Plan says the correct amount 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 20% 
coinsurance for Part B Drugs.  
 
You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B 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 coinsurance for Doxorubicin injections 
provided January 31, 2019 to February 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for catheter supplies (A4332, A4352, E1399) purchased from a 
supplier that does not participate in Medicare from February 4, 2020 to March 18, 2020. 
 
You asked the Plan to pay for catheter supplies. You say that these items were medically necessary. The Plan 
denied your request. The Plan says the supplier for these items is not certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The supplier for these items is not enrolled in the Medicare program. 
Based on this information, we decided that Medicare rules for coverage of catheter supplies have not been met. 
Therefore, we decided that the Plan does not have to pay for catheter supplies (A4332, A4352, E1399) 
purchased from a supplier that does not participate in Medicare from February 4, 2020 to March 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 28, 2020 by a non-
network provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-network provider without prior authorization. 
 
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 medical services provided on January 28, 2020 
by a non-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inlay, first intraoral periapical x-ray, and additional 
intraoral periapical x-ray provided on March 25, 2019. 
 
You asked the Plan to pay for the inlay and intraoral periapical x-rays. You say that you paid the dentist 
$1,505. You also say that the dentist was paid twice, once by you and once by the Plan. The Plan denied your 
request. The Plan says you have already received the maximum amount of coverage allowed for these services. 
 
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 offers a $1,700 annual dental 
benefit maximum. The contract says that you are responsible for any amount above the dental coverage limit. 
The record shows that you met the annual maximum benefit while processing this claim on March 25, 2019 
and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to 
pay for the inlay, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on March 25, 
2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the testing services rendered on January 
27, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that the services were during a routine 
physical and should be covered in full. The Plan denied your request. The Plan says the coinsurance was 
applied 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 20% 
coinsurance for diagnostic tests.  
 
Review of the file shows that you received venipuncture (blood collection) and testing services on January 27, 
2020. These services fall outside of the scope of an annual physical exam. You have been asked to pay a 20% 
coinsurance for these services. These services fall within the 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. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the testing services rendered on January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper and lower immediate denture (D5130 & D5140) 
and alveoloplasty (D7310) provided on January 30, 2020. 
 
You asked the Plan to pay for the upper and lower immediate denture (D5130 & D5140) and alveoloplasty 
(D7310). You say that according to the provider, insurance would cover the expenses. The Plan denied your 
request. The Plan says the services 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, 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 upper 
and lower immediate denture (D5130 & D5140) and alveoloplasty (D7310) provided on January 30, 2020.