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

 
We decided that the Plan does not have to waive the copayment for office visits provided on January 5, 2022, 
to August 26, 2022. 
 
You asked the Plan to waive the copayment for office visits. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $20 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $11.71 which is less than the $20 copayment for each office visit. This 
item/service falls within the physician/practitioner services, including doctor's office visits 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 office visits provided on January 5, 2022, to August 26, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on August 23, 2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that please review this claim, we do not 
treat anyone unless it is essentail. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a skilled nursing facility 
visit provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) during non-intracranial 
surgery (95955) provided on December 15, 2021. 
 
You asked the Plan to pay for the EEG. You say that based on the enrollee's condition, this procedure was 
medically necessary. The Plan denied your request. The Plan says the service was 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 pay for the EEG. Our reviewer says that the EEG 
was not considered medically reasonable and necessary in this case. Our physician reviewer found the EEG 
monitoring performed would not have been of any clinical diagnostic utility in this case. The reviewer found 
that the provided documentation does not indicate that the procedure was one in which there would have been 
concern for any intracranial changes. Therefore, the reviewer found that the EEG was not medically reasonable 
or necessary in this case. 
 
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 EEG have not been met. Therefore, we decided that the Plan does not have 
to pay for the electroencephalogram (EEG) during non-intracranial surgery (95955) provided on December 15, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82607, 84436, and 84443) billed for date of 
service July 19, 2022. You asked the Plan to pay for the lab services. You say that medical records were provided. The Plan denied 
your request. The Plan says the services are not a Medicare benefit when done for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows that vitamin B-12 (82607), total thyroxine (84436), and thyroid stimulating hormone (84443) 
were tested. We looked at the file and the rules. The records show that the enrollee received a wellness exam. 
There is no indication the testing was ordered due to signs and/or symptoms related to the testing. Medicare 
does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for 
lab services (82607, 84436, and 84443) billed for date of service July 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Retacrit. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of anemia of chronic kidney disease. The record indicates that the 
enrollee has a glomerular filtration rate of 36 milliliter per minute/1.73 meter square and hemoglobin values of 
10 milligrams (mg) per deciliter (dL) and less in January 2023 and has required the drug intermittently for a 
few years. The requested drug is indicated in enrollees for the treatment of anemia due to chronic kidney 
disease, including patients on dialysis and not on dialysis to decrease the need for red blood cell transfusion. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carrying bag and a privacy flap for a wheelchair. 
 
You asked the Plan to pre-approve a carrying bag and a privacy flap. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for durable 
medical equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a carrying bag and a privacy flap for a wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under codes 80307 and G0480 
provided on September 07, 2022. 
 
You asked the Plan to pay for laboratory services billed under codes 80307 and G0480. You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
billed under codes 80307 and G0480 provided on September 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under code 81479 provided on 
October 07, 2022. 
 
You asked the Plan to pay for laboratory services billed under code 81479. You say that you are appealing the 
claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
billed under code 81479 provided on October 07, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the posterior chamber intraocular lens (V2632) provided July 
12, 2022. 
 
You asked the Plan to pay for the surgical procedure. You say that you were informed that you were covered 
with a copay of $200. You had cataract surgery and the clinic billed you $268 that you were not expecting to 
pay. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the posterior chamber intraocular lens (V2632) 
provided July 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ofev. 
 
You asked the Plan to pre-approve Ofev. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ofev.  
 
Benefits for Ofev may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), single vision lenses (V2100), anti-reflective 
coating (V2750), and polycarbonate lenses (V2784) provided on October 19, 2022. 
 
You asked the Plan to pay for frames (V2020), single vision lenses (V2100), anti-reflective coating (V2750), 
and polycarbonate lenses (V2784). You say that you thought you could spend the $575 on sunglasses and 
regular glasses. You also say the sales lady told you were covered for both pairs. The Plan denied your request. 
The Plan says your benefit maximum has been met. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $575 allowance towards the cost of the lenses and one pair of eyeglass frames 
every year. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $575 vision allowance for routine 
contact lenses or eyewear every year from Plan providers. The Plan rules also say that routine eyewear includes 
the lenses, and one pair of eyeglass frames every year. This benefit was exhausted on October 19, 2022. Based 
on this information, we decided that the Plan's rules for coverage of frames (V2020), single vision lenses 
(V2100), anti-reflective coating (V2750), and polycarbonate lenses (V2784) have not been met. Therefore, we 
decided that the Plan does not have to pay for frames (V2020), single vision lenses (V2100), anti-reflective 
coating (V2750), and polycarbonate lenses (V2784) provided on October 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on August 29, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 had network providers 
available who could have provided 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 domiciliary services provided on August 29, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed under codes G0471, 85610, and 
P9604 provided on September 01, 2022. 
 
You asked the Plan to pay for laboratory services billed under codes G0471, 85610, and P9604. You say that 
you are appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
billed under codes G0471, 85610, and P9604 provided on September 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital, binaural hearing aid (V5261) provided on August 
22, 2022. 
 
You asked the Plan to pay for a digital, binaural hearing aid (V5261). You say that this provider is an in-
network provider, so you feel you are entitled to the $500 renumeration. The Plan denied your request. The 
Plan says hearing aids must be purchased through a Plan hearing provider to be covered under the hearing aid 
services offered by your 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 plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are provided through an in-network Plan hearing provider.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules say that hearing aids ordered through providers other 
than the Plan hearing providers are not covered. The record shows this provider is not an in-network Plan 
hearing provider. Based on this information, we decided that the Plan's rules for coverage of a digital, binaural 
hearing aid (V5261) have not been met. Therefore, we decided that the Plan does not have to pay for a digital, 
binaural hearing aid (V5261) provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Chiropractic manipulative treatment (CMT); spinal, 3-4 
regions provided on September 09, 2022. 
 
You asked the Plan to pay for Chiropractic manipulative treatment (CMT); spinal, 3-4 regions. You say that 
you are appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for Chiropractic 
manipulative treatment (CMT); spinal, 3-4 regions provided on September 09, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 30, 
2021, to May 12, 2021. 
 
You asked the Plan to pay for SNF care. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says the documentation provided does not contain the 
visit notes for the billed physical therapy visits on this claim. Therefore, this care is not supported as billed. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of SNF care have been met. Specifically, 
no visit notes/documentation for therapeutic services on the dates in question were included in the medical 
records. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care 
provided from April 30, 2021, to May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic casts (D0470) for teeth numbers 1 and 32, drugs 
or medicaments (D9630) for teeth numbers 1 and 32, autogenous connective tissue graft procedure (D4273) for 
tooth number 5, osseous surgery (D4261) for teeth numbers 9, 16, 17, 24, 25, and 32, and autogenous 
connective tissue graft (D4273) for tooth number 25 provided on May 24, 2022.  
You asked the Plan to pay for diagnostic casts (D0470) for teeth numbers 1 and 32, drugs or medicaments 
(D9630) for teeth numbers 1 and 32, autogenous connective tissue graft procedure (D4273) for tooth number 5, 
osseous surgery (D4261) for teeth numbers 9, 16, 17, 24, 25, and 32, and autogenous connective tissue graft 
(D4273) for tooth number 25. You say that the patient presented with chronic periodontitis at initial visit in the 
treated areas. The Plan denied your request. The Plan says these services are not covered under the member's 
contract under any normal circumstances. 
 
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 diagnostic 
casts (D0470) for teeth numbers 1 and 32, drugs or medicaments (D9630) for teeth numbers 1 and 32, 
autogenous connective tissue graft procedure (D4273) for tooth number 5, osseous surgery (D4261) for teeth 
numbers 9, 16, 17, 24, 25, and 32, and autogenous connective tissue graft (D4273) for tooth number 25 
provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three surgical extractions (D7210 x3) and removal of 
residual tooth roots (D7250) provided on September 27, 2022. 
 
You asked the Plan to pay for the surgical extractions and removal of residual tooth roots. You say that you 
were told that your insurance would not cover these services, and you had to pay the sum of $1,413.90 in order 
to proceed with the treatment. You also say that you could not handle the pain any longer, and think it is unfair. 
The Plan denied your request. The Plan says these services are not included on your benefit plan. 
 
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 the three 
surgical extractions (D7210 x3) and removal of residual tooth roots (D7250) provided on September 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided on August 17, 2022. 
 
You asked the Plan to pay for cataract surgery. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for cataract surgery 
provided on August 17, 2022.