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

 
We decided that the Plan does not have to pay for lens, polycarbonate or equal, any index, per lens (V2784) 
and Progressive lens, per lens (V2781) provided on July 10, 2020. 
 
You asked the Plan to pay for lens, polycarbonate or equal, any index, per lens and progressive lens, per lens. 
You say that you were unaware the service was not covered. The Plan denied your request. The Plan says the 
service is not a covered 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. Enhancements are not covered through the allowance but may be purchased by the member at an 
additional cost. 
 
We looked at the file and the Plan's rules. The service received is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of lens, polycarbonate or equal, any index, per lens 
and progressive lens, per lens have not been met. Therefore, we decided that the Plan does not have to pay for 
lens, polycarbonate or equal, any index, per lens (V2784) and Progressive lens, per lens (V2781) provided on 
July 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Shingrix vaccine. 
 
You asked the Plan to pre-approve the vaccine. You say that this should be covered due to a couple of blood 
diseases. The Plan denied your request. The Plan says this is not covered by Medicare Part B, and therefore not 
covered by the plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pre-approve the Shingrix vaccine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the co payment from $25 to $15 for the ophthalmological 
services, medical examination and evaluation, with initiation or continuation of a diagnostic and treatment 
program, for an established patient (92014) provided. 
 
You asked the Plan to reduce the co payment from $25 to $15. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost sharing 
has been applied correctly to the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $25 for 
each Medicare-covered outpatient visit for services to diagnose and or treat a disease or condition of the eye.   
 
You have been asked to pay $25 for the Medicare-covered outpatient visit provided to diagnose and or treat a 
disease or condition of the eye. 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 reduce the co payment from $25 to $15 for the 
ophthalmological services, medical examination and evaluation, with initiation or continuation of a diagnostic 
and treatment program, for an established patient (92014) provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (22899). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this is necessary for pain relief. The 
Plan denied your request. The Plan says this is experimental. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental for back pain. More research is needed to 
show safety and efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (22899).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve complete replacement of shoulder joint, and partial removal of 
collar bone for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested service is supported when there are x-rays and detailed picture studies 
showing a problem in the shoulder. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presents with chronic left shoulder pain with associated popping and clicking. Pain is grade 
3/10 at rest and significantly increased with activities of daily living. Clinical exam findings have been 
consistent with radiographic evidence of severe glenohumeral osteoarthritis, acromioclavicular (AC) joint 
osteoarthritis, and chronic grade 2 AC separation. He has failed to achieve sustained improvement with activity 
modification, medications, physical therapy, chiropractic, cortisone injection and home exercise program. 
Under consideration is a request for left total shoulder replacement and distal clavicle excision. Current 
evidence based medical guidelines would support surgical intervention based on the enrollee's significant 
symptoms, functional limitations, clinical findings, severe left shoulder osteoarthritis, and failed conservative 
treatment. Therefore, this request for left total shoulder replacement and distal clavicle excision is 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 services have been met. Therefore, we decided that the Plan has to pre-
approve complete replacement of shoulder joint, and partial removal of collar bone for the enrollee.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740). 
 
You asked the Plan to pre-approve the porcelain/ceramic crown. You say that the service is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the provider is billing for 
an inappropriate code and the procedure will not be 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. The Plan covers the 
porcelain/ceramic crown when the services are medically necessary and reasonable.  
 
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 porcelain/ceramic crown. Our 
reviewer says that the service is not being billed correctly. Our physician reviewer found an incorrect treatment 
code is currently being billed. The correct code that should be used is D6752, retainer crown - porcelain fused 
to noble metal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the porcelain/ceramic crown have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the porcelain/ceramic crown (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 
21, 2020. 
 
You asked the Plan to pay for the dental service. You say that you had a new benefit added that allows 2 
cleanings covered in full. You also say that the price of a regular cleaning should be deducted from the price of 
the maintenance cleaning. The Plan denied your request. The Plan says periodontal maintenance is not listed as 
a covered service. 
 
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 
periodontal maintenance (D4910) provided on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection provided on April 30, 2020. 
 
You asked the Plan to pay for Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with 
imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to 
code for primary procedure) (64484). You say that the Plan should pay this claim. The Plan denied your 
request. The Plan says an add-on code is eligible for payment if one of the listed primary procedure codes is 
also eligible for payment to the same practitioner for the same patient on the same date of service. 
  
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, we have confirmed that code 64484 
cannot be paid as billed. This code was billed without a primary code for this physician and cannot be paid as a 
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the injection provided on April 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a breast biopsy (19081) provided on March 17, 2020. You asked the Plan to pay for a breast biopsy. You say that this was billed correctly. The Plan denied your request. The Plan says this procedure is not documented. 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 19081 is biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance. We find that CPT code 19081 is not supported in the medical record. Specifically, the submitted medical records do not include documentation of a biopsy. Based on this information, we decided that Medicare rules for coverage of a breast biopsy have not been met. Therefore, we decided that the Plan does not have to pay for a breast biopsy (19081) provided on March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the complete series of intraoral x-rays. We decided that the Plan does 
not have to pay for the 2D oral/facial photographic image and cone beam CT capture and interpretation.  
 
You asked the Plan to pay for the 2D oral/facial photographic image, cone beam CT capture and interpretation, 
and complete series of intraoral x-rays. You say that you cannot afford to pay for these services. The Plan says 
that these services are not covered benefits. The Plan also says that panoramic x-rays are only covered once per 
year, and this has already been approved. 
 
We decided that the Plan has to pay for the complete series of intraoral x-rays.  
 
 
 
The rules say that the health plan must provide you with a clear and accurate description of the Original 
Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including 
applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits.  
 
We looked at your contract with the Plan. We did not see where the contract clearly says enrollees can only 
receive either one panoramic x-ray or one intraoral x-ray once per year. You reasonably believed that the 
complete series of intraoral x-rays would be covered, because your contract states that intraoral x-rays are 
covered once per year. Therefore, we decided that the Plan has to pay for the complete series of intraoral x-
rays.  
 
We also decided that the Plan does not have to pay for the 2D oral/facial photographic image and cone 
beam CT capture and interpretation. 
 
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 2D 
oral/facial photographic image and cone beam CT capture and interpretation. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on July 8, 2020. 
 
You asked the Plan to pay for core buildup, including any pins when required. You say that the service was 
medically necessary. The Plan denied your request. The Plan says procedure code D2950 for filling or pins 
placed when preparing a tooth for a crown must be performed together with a crown. 
 
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. Specifically, you did not receive a crown with your buildup. 
Therefore, we decided that the Plan does not have to pay for core buildup, including any pins when required 
(D2950) provided on July 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 16, 2020. You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $85 copayment for ultrasounds. You have been asked to pay an $85 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an ultrasound provided on July 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the treatment of bladder lesions provided 
from February 18, 2020, to March 3, 2020. 
 
You asked the Plan to waive the copayments for the treatment of bladder lesions. You say that you disagree 
with the $238.56 charges for exam time because you only paid $20 in the past. 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You received the treatment of bladder lesions from February 18, 2020, to March 3, 2020, for a total of 3 visits. 
The treatment of bladder lesions is considered an outpatient surgical procedure. Therefore, you are responsible 
to pay the allowed amount of $238.56, which is less than the $250 copayment, per each visit. The total amount 
you owe is: $238.56 (copayment) x 3 (surgery visits) = $715.68.   
 
You have been asked to pay the total copayment amount of $715.68 for the treatment of bladder lesions. The 
treatment of bladder lesions fall within the outpatient surgery, including 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 the treatment of bladder lesions provided from February 18, 2020, to March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 25, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 the enrollee by an out-of-network provider 
on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that you don't like needles and 
need the Continuous Glucose Monitor to check your blood sugar. The Plan denied your request. The Plan says 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a Continuous Glucose Monitor is covered when 
you require insulin injections at least three times per day or use an insulin pump. 
 
We looked at the file and Medicare rules. The record shows you are not using injectable insulin or an insulin 
pump. The record shows only oral medication is being taken. Based on this information, we decided that 
Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on July 23, 2020.
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says the criteria requires documentation the member has decided to seek further treatment (such as therapeutic chemotherapy). The Plan states the clinical information submitted states the member is under surveillance.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say that providers must use the appropriate CPT codes and when necessary provide specific documentation to show the services billed met Medicare billing criteria. In this case, the records provided do not show the enrollee met the required coverage criteria are the time of service. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on July 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the co payment for the echo cardiogram you had at an 
outpatient hospital facility. 
 
You asked the Plan to reduce the co payment for the echo  cardiogram. You say that you were told by the staff at 
the hospital that your co payment would only be $40. The Plan denied your request. The Plan says you were 
charged this co payment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
co payment for diagnostic procedures and tests at an outpatient hospital facility.  
  
You have been asked to pay a $100 co payment for the echo cardiogram. The echo cardiogram falls within the 
diagnostic procedures and tests at an outpatient hospital facility 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 reduce the co payment for the echo cardiogram you had at an outpatient hospital facility.