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

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the MyoPro Motion G orthotic device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says the orthotic device 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 MyoPro Motion G orthotic device. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the records do not detail what other orthotics were trialed and failed. The record 
does not include any occupational therapy notes. There is no specific clinical rationale for the requested 
MyoPro Motion G orthotic device. 
 
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 MyoPro Motion G orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a MyoPro Motion G orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for protective restoration (D2940) provided July 21, 2020 to 
August 31, 2020. 
 
You asked the Plan to pay for the dental services. You say that the dental office had received approval for the 
services. The Plan denied your request. The Plan says this service is not covered under the plan benefits. 
 
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 health plan contract 
specifically says that procedures not listed in the Plan's dental directory are not covered. 
 
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 protective 
restoration (D2940) provided July 21, 2020 to August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services provided on August 4, 2020. 
 
You asked the Plan to waive the copayment for the physician's services. The Plan denied your request. The 
Plan says you are responsible for a $30 copayment for vision services rendered by an in-network provider. 
 
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 $30 
copayment for vision care, in-network Medicare covered vision services. 
 
You have been asked to pay $30 copayment for the physician's services. The physician's services falls within 
the vision care, in-network Medicare covered vision services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for physician's services provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the sacroiliac joint injection provided. 
 
You asked the Plan to waive the copayment for the sacroiliac joint injection. You say that at the time of service 
you were advised the copayment would be $89.82. You say that you disagree with the additional cost and you 
shouldn't have to pay it. The Plan denied your request. The Plan says the copayment 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 $275 
copayment for Medicare-covered surgery or other services provided to you at an in-network ambulatory 
surgical center or outpatient hospital, including but not limited to hospital or other facility charges and 
physician or surgical charges.  
 
You have been asked to pay a $275 copayment for the sacroiliac joint injection. The sacroiliac joint injection 
falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan.  
 
 
 
 
 
 
 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the sacroiliac joint injection provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite fillings (D2393) provided on 
August 4, 2020. 
 
You asked the Plan to pay for the resin-based composite fillings. You say that you were not aware there was a 
limitation to the dental services you received. The Plan denied your request. The Plan says you have exhausted 
the benefit limit for this 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. The Plan covers the resin-
based composite fillings twice a year.  
 
We looked at the file and Medicare rules. The file indicates that you previously received reimbursement for 
two fillings from February 2020, and thus exhausted your coverage benefit. Based on this information, we 
decided that the Plan's rules for coverage of the resin-based composite fillings have not been met. Therefore, 
we decided that the Plan does not have to pay for the resin-based composite fillings (D2393) provided on 
August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to a lower extremity prosthesis. 
 
You asked the Plan to pre-approve the addition. You say that this is medically necessary. The Plan denied your 
request. The Plan says the Revo tension socket system does not have FDA approval. 
 
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 addition. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the Revo tension socket 
system at issue in this case medically reasonable and necessary as there is no evidence the device is approved 
by the Food and Drug Administration as safe and effective. 
 
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 addition have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition to a lower extremity prosthesis.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the $105 copayment for audiology services provided on August 13, 
2020. 
 
You asked the Plan to waive the $105 copayment for the audiology services provided on August 13, 2020. The 
Plan denied your request. The Plan says that the claim denied correctly. 
 
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 enrollees must pay $25 copayment for in-network Medicare covered hearing 
services.  
 
The Plan says you must pay $105 copayment for the audiology services provided on August 13, 2020. Based 
on the Plan contract, however, you cannot be asked to pay more than $25 copayment for the audiology services 
provided on August 13, 2020. Therefore, we decided that the Plan has to waive the $105 copayment for 
audiology services provided on August 13, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on page July 1, 2020. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says hearing 
aids must be purchased through the Plan's hearing aid provider to be covered under the hearing aid services 
offered by the Plan. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by the Plan's hearing aid provider. 
 
We looked at the file and the Plan's rules. The requested provider in this case is not a network hearing aid 
provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the hearing 
aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids 
provided on page July 1, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on August 17, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were given the option to stay 
overnight and you chose not to. The Plan denied your request. The Plan says the copayment 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 $120 
copayment for each Medicare-covered emergency care visit inside the United States. 
 
You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that you were treated in the ER. 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 ER visit provided on August 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytogenetics and molecular cytogenetics coded 88291 
provided on May 23, 2020. 
 
You asked the Plan to pay for the cytogenetics and molecular cytogenetics. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services cannot be paid as 
billed. 
 
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 88291 is cytogenetics and molecular cytogenetics, 
interpretation and report. 
 
We find that CPT code 88291 is not supported in the medical record. Specifically, these services were billed 
with place of service 22 (outpatient). However, the documentation shows that the enrollee was inpatient for this 
date of service (place of service 22). Therefore, the services cannot be paid as billed. Based on this information, 
we decided that Medicare rules for coverage of the cytogenetics and molecular cytogenetics have not been met. 
Therefore, we decided that the Plan does not have to pay for the cytogenetics and molecular cytogenetics coded 
88291 provided on May 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on September 17, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit and related services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 and related services provided on September 17, 2020 by an out of network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions provided on August 24, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were charged $39 for a preventive service. 
You say that you only received a standard cleaning. You also say that you should not have to pay for something 
you had no knowledge of. The Plan denied your request. The Plan says oral hygiene instruction is excluded 
from coverage. 
 
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 oral 
hygiene instructions provided on August 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve increase from 4 
hours per day to 6 hours per day (G0156). 
 
You asked the Plan to pre-approve increased from 4 hours per day to 6 
hours per day. You say that the services are medically necessary. The Plan denied your request. The Plan says 
there is no clinical evidence to support the need for increased Home Health Aide (HHA) Services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 increased Home Health Aide (HHA) 
Services from 4 hours per day to 6 hours per day. Our reviewer says that the service is not medically necessary. 
Our physician reviewer found in order to require Home health care skilled services, the member must be 
confined to the home, under the care of a physician, and receiving services under a plan of care established and 
periodically reviewed by a physician.  Additionally, the member must be in need of skilled nursing care on an 
intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational 
therapy.  Being homebound means leaving home is a major effort.  In this case, the documentation doesn't 
support that the member requires increased home health aide hours.  There is no indication that the members 
function has declined. The member has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of increased  from 4 hours per day to 6 hours 
per day have not been met. Therefore, we decided that the Plan does not have to pre-approve increased Home 
Health Aide (HHA) Services from 4 hours per day to 6 hours per day (G0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device coded E0675 and 
appliances coded as E0673 provided on June 5, 2020. 
 
You asked the Plan to pay for pneumatic compression device. You say that the Plan has paid you less than the 
appropriate amount for these items. The Plan denied your request. The Plan says the denial of payment for 
these items is correct, because these items are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device E0675 is not 
covered by Medicare, and related accessories are also not covered.  
 
We looked at the file and Medicare rules. The billed E0675 device is not covered by Medicare. Because this 
device is not covered, the related E0673 accessories are also not covered. Based on this information, we 
decided that Medicare rules for coverage of pneumatic compression device have not been met. Therefore, we 
decided that the Plan does not have to pay for a pneumatic compression device coded E0675 and appliances 
coded as E0673 provided on June 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic radiology simulation-aided field setting (77280) 
radiation treatment delivery (77412) provided on June 18, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiation treatment services. You say that you are requesting reconsideration 
of the denial, review of the medical records and approval of the services provided. The Plan denied your 
request. The Plan says enrollee's must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 therapeutic radiology simulation-aided field 
setting (77280) radiation treatment delivery (77412) provided on June 18, 2020, by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Synvisc is covered when specific criteria are met. 
 
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 these services. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found the enrollee has right knee osteoarthritis. There is no documentation 
that he has tried and failed non-pharmacologic therapy, including simple analgesics, non-steroidal anti-inflammatory 
drugs (NSAIDs), and intra-articular corticosteroid injection therapy. The Synvisc is therefore not reasonable or medically 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve 
Synvisc.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 4, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says no prior authorization was obtained to have the services rendered. 
 
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 lab services at issue. The Plan did not pre-approve the services at issue. We found no 
exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does 
not have to pay for the lab services provided on May 4, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an occlusal adjustment (D9951) performed on August 4, 
2020. 
 
You asked the Plan to pay for an occlusal adjustment. You say that you were never told this was a once-a-year 
treatment. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 an 
occlusal adjustment (D9951) performed on August 4, 2020.  
 
Your complaint about receiving erroneous or incomplete information about your benefits from your dental 
provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.