Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist telemedicine visit 
provided on December 6, 2022. 
 
You asked the Plan to waive the copayment for a telemedicine visit. You say that you have never been charged 
for a telemedicine visit before. 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 a $30 
copayment for an in-network specialist telemedicine visit.  
 
You have been asked to pay a $30 copayment for a telemedicine visit. This item/service falls within the in-
network specialist telemedicine visit benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an in-network specialist telemedicine visit provided on December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames, the single vision sphere, the prism, the 
polycarbonate lens, the ultraviolet lens, and the anti-reflective coating provided on August 29, 2022. 
 You asked the Plan to pay for the vision services. You say that you were charged $80 erroneously. You say 
your provider is in-network. The Plan denied your request. The Plan says the claim was reprocessed correctly. 
 
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 these services up to the $275 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $275 towards the vision services which 
exhausted the benefit. Based on this information, we decided that the Plan's rules for coverage of the vision 
services have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe frames, the 
single vision sphere, the prism, the polycarbonate lens, the ultraviolet lens, and the anti-reflective coating 
provided on August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose Monitor (CGM), supplies and 
accessories. 
 
You asked the Plan to pre-approve the CGM, supplies and accessories. The Plan denied your request. The Plan 
says you do not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM, 
supplies and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose Monitor (CGM), supplies and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing-four or more teeth 
per quadrant (D4341 x 2) provided on July 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the services provided was exhausted on date of service July 5, 2022. Specifically, the 
Plan provides a $1,500 combined dental allowance for supplemental preventive and comprehensive dental 
services every year. Members are responsible for any amount over and above the allowance amount.  You previously received dental services on June 25, 2022, June 30, 2022, and July 5, 2022. The Plan issued 
payment for these services in the amount of $1,500. Therefore, you have exhausted the allowable benefit for 
these services. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root 
planing-four or more teeth per quadrant (D4341 x 2) provided on July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the power wheelchair replacement motor 
provided by an in-network provider on April 21, 2022. 
 
You asked the Plan to waive the copayment for the power wheelchair replacement motor. You say that you 
would like the cost sharing to be lower. 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 a $10 
copayment for in and out-of-network Medicare-covered durable medical equipment. 
 
 
 
 
 You have been asked to pay a $10 copayment for the power wheelchair replacement motor. This item/service 
falls within the durable medical equipment (DME) and related 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 the power wheelchair replacement motor provided by an in-network 
provider on April 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of lumbar spine 
without contrast (72148). 
 
You asked the Plan to pre-approve an MRI of lumbar spine without contrast. You say that the service is 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of lumbar spine without 
contrast. Our reviewer says that the service is not medically necessary. Our physician reviewer found detailed 
documentation is not evident regarding any lumbar complaints or objective findings on a recent exam. There is 
no documentation of a trial and failure of recent, reasonable, comprehensive less invasive conservative care 
measures. Detailed evidence of severe and/or progressive neurological abnormalities has not been documented. 
You had a lumbar MRI on March 23, 2020 (and without any documentation of such significant changes), 
repeat imaging is not supported. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. 
 
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 MRI of lumbar spine without contrast have not been met. Therefore, we 
decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of lumbar spine without 
contrast (72148).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93325 billed for date of service August 10, 
2022. 
 You asked the Plan to pay for procedure code 93325. You say that procedure code 93325 should be approved 
and paid. The Plan denied your request. The Plan says payment for code 93325 is bundled into payment for 
code 33361. 
 
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 93325 
is a column II code to column I code 33361. 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 procedure code 93325 billed for date of service August 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on August 
22, 2022. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that the records attached support 
the services provided. 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 subsequent nursing 
facility care visit provided on August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee's health is declining. The 
enrollee has acute and chronic respiratory failure with COPD. The Plan denied your request. The Plan says the 
request for a home mechanical ventilator set in iVAPS mode with Auto-EPAP (AE) that could be delivered by 
BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD with a 
recent hospitalization. ABG was consistent with acute on chronic hypercarbic respiratory failure.  There is no 
ABG done while stable to document chronic CO2 retention.  If the enrollee does have chronic CO2 retention, 
he may benefit from BiPAP with AVAPS during sleep. Medicare does not cover a home ventilator when used 
at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on 
September 7, 2022. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says NMES is not covered for the documented diagnoses. 
 
The Plan follows Medicare rules. Medicare rules say that NMES to treat muscle atrophy is limited to the 
treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and 
peripheral nerves, and other non-neurological reasons for disuse atrophy. 
 
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 neuromuscular stimulator. Our reviewer 
says that the request was not medically reasonable and necessary. Our physician reviewer found there is a lack 
of supporting documentation.  
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 neuromuscular stimulator have not been met. Therefore, we decided that the 
Plan does not have to pay for the neuromuscular stimulator (E0745) provided on September 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee's status does not meet medical necessity severity or intensity 
criteria for Acute Inpatient Rehabilitation Admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found while the enrollee may benefit from PT, and OT, the enrollee's rehab needs can be 
provided in a lower intensity and alternate setting such as in an SNF.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hearing test provided on September 13, 
2022. 
 
You asked the Plan to waive the copayment for the hearing test. You say that you thought this would have a $0 
copayment due to it being a routine hearing exam. 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 a $30 
copayment for each Medicare-covered hearing visit.  
 
The medical records show you received diagnostic hearing services. You have been asked to pay a $30 
copayment for the hearing test. This item/service falls within the hearing 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 a hearing test provided on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a chest x-ray provided on November 28, 
2022. 
 
You asked the Plan to waive the copayment for the chest x-ray. You say that the services should have been 
included as pre-op services. 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 a $90 
copayment for basic radiological services at an outpatient hospital.  
 
You have been asked to pay a $90 copayment for a chest x-ray. This item/service falls within the outpatient 
diagnostic tests and therapeutic 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 a chest x-ray provided on November 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is at risk for re-admission to 
a hospital if they receive lower-level care. The Plan denied your request. The Plan says an LTACH admission 
is not medically necessary, and the enrollee can receive the care they need in the current hospital setting. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care setting. 
 
   
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on October 12, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that your visit was to have 
your teeth cleaned. You also say that the dentist informed you that you have to have the cleaning done by a 
periodontist. The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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 a 
comprehensive periodontal evaluation (D0180) provided on October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - three radiographic images (D0273) provided on 
October 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received a bill and did not realize you 
already had an x-ray. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
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. This benefit includes the 
requested bitewings - three radiographic images (D0273) but is limited to one procedure per plan year. 
 
  We looked at the file, the Plans rules, and Medicares rules. You previously received covered bitewings - four 
radiographic images (D0274) on February 1, 2022, and bitewings - three radiographic images (D0273) on 
October 11, 2022. Although these are two different services they fall within the same category in your 
Evidence of Coverage and are subject to the same frequency limitations. Therefore, this benefit was exhausted 
as of February 1, 2022. Therefore, we decided that the Plan does not have to pay for bitewings - three 
radiographic images (D0273) provided on October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographs (D0350) provided on 
November 9, 2022. 
 
You asked the Plan to pay for the photographs. You say that the x-rays were medically necessary. The Plan 
denied your request. The Plan says that 2D oral/facial photographs (D0350) are not covered by your dental 
benefits. 
 
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 2D 
oral/facial photographs (D0350) provided on November 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 04, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. 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 the laboratory services 
provided on October 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis provided on September 02, 2022, to September 05, 
2022. 
 
You asked the Plan to pay for dialysis. You say that you are requesting reconsideration. 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 dialysis provided on 
September 02, 2022, to September 05, 2022.