Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on January 20, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says an eye refraction 
is not a covered benefit since it was medical vision check (Type 2-diabetes, Age-related nuclear cataract). Eye 
refractions are only covered by your Plan if performed by a participating vision provider and performed as a 
routine screening per your 2022 Evidence of Coverage. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam services (92004, 76514) 
provided on January 7, 2022. 
 
You asked the Plan to waive the copayment for the vision services. You say that you should have had a $0 
copayment for these services. The Plan denied your request. The Plan says this claim was processed correctly, 
and your responsibility was assessed in accordance with your contract.  
 
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 $35 
copayment for Level 1 physician services to diagnose and treat diseases and conditions of the eye.  You have 
been asked to pay a $35 copayment for the vision services. The vision services fall within the Level 1 
physician services to diagnose and treat diseases and conditions of the eye 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 eye exam services (92004, 76514) provided on January 7, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Triluron for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria were not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 drug. Our reviewer says that the 
Our physician reviewer found the provided documentation does not clearly show that the patient had tried and 
failed Durolane, Monovisc, Orthovisc, Supartz FX, or Synvisc-One. The preferred drug options would not 
likely be less effective or cause more adverse side effects as these similar agents are in the same drug class and 
based on comparative studies have been shown to essentially have the same effectiveness and safety. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Triluron for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2330, D2332, D2392), and a 
crown re-cement (D2920) provided by a participating provider on December 9, 2021, to December 16, 2021. 
 
You asked the Plan to pay for resin-based composites and a crown re-cement. You say that you do not agree 
with these charges. The Plan denied your request. The Plan says this claim has been processed correctly. 
 
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 two resin-
based composites every 12 months. A crown re-cement is not a covered dental benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of resin-based composites have not been met. D2920 is not a covered dental benefit. Therefore, we 
decided that the Plan does not have to pay for resin-based composites (D2330, D2332, D2392), and a crown re-
cement (D2920) provided by a participating provider on December 9, 2021, to December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on December 31, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on December 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on 
December 21, 2021. 
 
You asked the Plan to pay for a crown. You say that you were hoping the Plan would let you use your 2022 
benefits. The Plan denied your request. The Plan says the annual maximum limit has already been met for 
2021. 
 
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 a maximum 
allowance amount of $2,000 for covered dental services. We looked at the file, and Medicare rules. 
The $2,000 allowance for 2021 was met at the time of this service. 
Based on this information, we decided that the Plan's rules for coverage of a crown have not been met. 
Therefore, we decided that the Plan does not have to pay for a crown (D2740) provided by a participating 
provider on December 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to still be somewhat unstable and require short-term additional services 
that can safely be completed at the current facility until you are more stable and appropriate for a lower level of 
care with a more permanent feeding solution. You do not require services at the LTACH that are not already 
available at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous. Transfer to a lower level of care may be considered when treatment has completed and you are 
more stable. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided on 
April 28, 2021. 
 
You asked the Plan to pay for fluoride varnish. You say that there was a misunderstanding with your coverage 
and an exception should be made in this case. The Plan denied your request. The Plan says this service is not 
covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 topical 
application of fluoride varnish (D1206) provided on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Prolia. Our reviewer says that the 
requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires either a 
a history of osteoporosis-related fracture or a trial of zoledronic acid before they will approve the requested 
drug. The records show that the enrollee does not have a history of osteoporosis-related fracture and has not 
tried zoledronic acid. There is no indication that zoledronic acid is likely be less effective or have adverse 
effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a sacroiliac (SI) joint injection procedure 
(code G0260) provided on November 30, 2021. 
 
You asked the Plan to waive the copayment for an injection procedure. You say that this was a simple SI 
injection and was in no way an outpatient surgery. 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 $300 
copayment for each outpatient surgical service.  
 
The record shows that a SI joint injection procedure (code G0260) is considered a surgical service. You have 
been asked to pay a $300 copayment for an injection procedure. An injection procedure falls 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 copayment for a sacroiliac (SI) joint 
injection procedure (code G0260) provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-cementing a crown (D2920) provided by a participating 
provider on January 13, 2022. 
 
You asked the Plan to pay for re-cementing a crown. You say that you needed this done because you crown 
was loose. The Plan denied your request. The Plan says D2929 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 re-
cementing a crown (D2920) provided by a participating provider on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on December 
23, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to the urgent care 
center on December 23, 2021, to have stitches removed. You also say you were assured you would not be 
charged. 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 $55 
copayment for an in and out of network urgent care visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $54.11, which is less than the $55 copayment for an urgent care visit. An urgent care 
visit falls within the Urgently Needed 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 an urgent care visit provided on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), and a periodic oral evaluation (D0120) 
provided by an out-of-network provider on February 7, 2022. 
 
You asked the Plan to pay for prophylaxis and a periodic oral evaluation. You say that this is fraud. You say 
that the Plan needs to hold up their end of the bargain. The Plan denied your request. The Plan says the claim 
has been processed correctly. 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of prophylaxis and a periodic oral evaluation have not been met. Therefore, we decided that the Plan 
does not have to pay for prophylaxis (D1110), and a periodic oral evaluation (D0120) provided by an out-of-
network provider February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, anterior tooth (excluding final 
restoration) (D3310) provided January 28, 2022. 
 
You asked the Plan to pay for the root canal. You say that you were not aware that this service would not be 
covered in 2022. The Plan denied your request. The Plan says this service is not covered under your 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. 
 
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 
endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided January 28, 2022.  
Your complaint about potentially not being informed about coverage changes for 2022 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.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown. We decided that the Plan does not have to pre-approve a 
core build-up.  
 
You asked the Plan to pre-approve a crown and a core build-up. You say that these services are not medically 
necessary. The Plan says that the criteria for D2740 and D2950 has 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. The Plan covers D2740 and 
D2950 when the services are medically necessary and reasonable. 
 
We decided that the Plan has to pre-approve a dental crown (D2740) for tooth #30.  
We also decided that the Plan does not have to pre-approve a core-build up (D2950) for tooth #30. 
 
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 crown and a core build-up. Our 
reviewer says that these services are only partially favorable. Our physician reviewer found the medical criteria 
for D2740 has been met. The medical criteria for D2950 have not been met. Documentation would be needed 
once the crown is removed to check the medically necessity of D2950. 
 
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 for D2950 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve D2950. The Plan must approve D2740. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Anesthesia complicated by emergency conditions 
(99140) provided on August 15, 2021. 
 
You asked the Plan to pay for code 99140. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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. 
 We find that CPT code 99140 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99140 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of code 99140 have not been met. Therefore, we decided that the Plan does not have to pay for the Anesthesia 
complicated by emergency conditions (99140) provided on August 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a complete mandibular denture (D5120) 
provided by a participating provider on January 31, 2022. 
 
You asked the Plan to waive the coinsurance for a complete mandibular denture. You say that you should not 
owe anything. The Plan denied your request. The Plan says the correct coinsurance has been 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 50% 
coinsurance for complete dentures.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for a complete mandibular denture. The 
total allowed amount is $887.83. The total amount you are being asked to pay is $443.92 ($887.83 x 50% = 
$443.92). The correct coinsurance has been applied to the dentures that were provided. A complete mandibular 
denture falls within the complete dentures 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 a complete mandibular denture (D5120) provided by a participating provider on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 5, 2022. 
 
You asked the Plan to pay for dental services. You say that you were told that this provider was in-network. 
The Plan denied your request. The Plan says services provided by an out-of-network provider are not covered 
or paid. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers covered 
dental services when the services are provided in-network. 
 
We looked at the file and Medicare rules. The rendering dentist became a participating provider on February 1, 
2022; therefore, at the time of January 5, 2022, the rendering dentist was out-of-network. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we 
decided that the Plan does not have to pay for dental services provided on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on September 16, 2021 to 
October 5, 2021. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
provider submitted a claim for procedure code 99199 (unlisted special service, procedure or report). This code 
is not covered when billed by a chiropractor. Therefore, we decided that the Plan does not have to pay for the 
chiropractic services rendered on September 16, 2021 to October 5, 2021.