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

 
We decided that the Plan does not have to pay for ambulance transportation provided in the United Mexican 
States on October 23, 2022. 
 
You asked the Plan to pay for ambulance transportation. You say that this was certainly medically necessary 
emergency care. The Plan denied your request. The Plan says the Plan paid this claim up to the Medicare 
allowable amount less the enrollee's cost-sharing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States are not covered except in limited, specified circumstances. The Plan has a worldwide coverage 
benefit that goes beyond Medicares coverage. For that reason, the Plans rules apply to this case. The Plan 
covers out-of-country emergency and urgently-needed care, including emergency ambulance transportation to 
the nearest appropriate facility. The Plan will pay for covered services at the Original Medicare reimbursement 
rates less any cost-sharing. The Plan contract clearly says that enrollees must pay $200 copayment for each 
covered one-way ambulance trip. 
 
We looked at the file and Medicare rules. This ambulance service does not fall within any of the circumstances 
for which Medicare covers items and services furnished outside of the United States. However, the Plan did 
cover this service under the enrollees worldwide coverage benefit. In accordance with the Plans rules, the 
Plan covered this service at the allowed amount of $157.20. Therefore, the enrollee is responsible for a 
copayment amount of $157.20 because this amount is less than the $200 copayment for a one-way ambulance 
trip. Therefore, the Plan issued no reimbursement for this service. Therefore, we decided that the Plan does not 
have to pay for ambulance transportation provided in the United Mexican States on October 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 16, 2021. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-one surface, posterior for tooth 
number 3 (D2391) provided on November 30, 2022. 
 
You asked the Plan to pay for this service. 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 service 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 service provided was exhausted on date of service October 26, 2022.  Specifically, the Plans contract states that fillings are covered once every 24 months per surface, per tooth. 
You previously received a filling for the same tooth on October 26, 2022, which was paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for this service at this time. Therefore, we decided that the 
Plan does not have to pay for the resin-based composite-one surface, posterior for tooth number 3 (D2391) 
provided on November 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (tildrakizumab-asmn) treatments. 
 You asked the Plan to pre-approve the treatment with Ilumya. You say that you and the enrollee feel that 
Ilumya is the best option for treatment. You note that many of preferred drugs mentioned are not Food and 
Drug Administration (FDA)-approved for plaque psoriasis and the ones that are require self-administration. 
The enrollee prefers to get treatment in the office due to prior issues with other self-administered drugs. The 
Plan denied your request. The Plan says this cannot be approved without a trial of preferred drugs. 
 
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 treatment with Ilumya. Our 
reviewer says that the use of Ilumya is not considered medically reasonable and necessary based on step 
therapy rules. Our physician reviewer found the enrollee has a diagnosis of Psoriasis vulgaris. The Plan 
requires a trial of two of the following drugs: adalimumab, Rinvoq, Skyrizi, Actemra, Cosentyx, Otezla, 
Xeljanz, Xeljanz XR, Orencia or Enbrel.before they will approve the requested drug. The case file does not 
contain documentation of trial and failure of two of the required drugs. The documentation does not support 
that two of the required drugs would less effective, and/or would likely have adverse effects for the enrollee 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 treatment with Ilumya have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Ilumya (tildrakizumab-asmn) treatments.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from October 6, 2021, to 
October 7, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says the enrollee had no documentation unstable angina, acute coronary 
syndrome, life-threatening arrhythmia, or barrier to stress testing on an outpatient basis. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the review has determined that the record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services rendered from October 6, 2021, to October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on December 13, 2022. 
 
You asked the Plan to pay for the refraction. You say that you thought the $65 was your copayment. You say 
you did not need a prescription because you are intending to have eye surgery. The Plan denied your request. 
The Plan says the service was not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers the refraction when performed as a part of the routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the refraction provided on December 13, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and fundus photography with 
interpretation and report (92250) provided on October 6, 2022, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the eye exam and fundus photography. You say that there was no indication that 
the enrollee's insurance plan was OON for your provider. You also say by the time you were made aware that 
the enrollee's insurance was OON, the enrollee was due for the next visit for a potentially serious condition if it 
were left untreated. The Plan denied your request. The Plan says these services are not authorized because the 
treating provider is a non-network provider who does not work with the enrollee's health plan. The Plan also 
says the enrollee self-directed for care. 
 
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 the eye exam (92014) and fundus photography 
with interpretation and report (92250) provided on October 6, 2022, 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 periodic oral evaluation (D0120), bitewing x-rays-four 
radiographic images (D0274), intraoral-periapical first radiographic image (D0220), intraoral-periapical 
additional radiographic image (D0230), and the dental cleaning (D1110) provided on December 15, 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 that your benefit for the services provided in this case has been exhausted. Specifically, the Plan contract 
states that two periodic oral evaluations are covered per year. You previously received this service on  
February 15, 2022 and June 29, 2022, which were paid for by the Plan. The Plan contract covers one set of 
bitewing x-rays every year. You previously received this service on June 29, 2022, which was paid for by the 
Plan. The Plan contract states that one intraoral radiographic image is covered per year. You previously 
received this service on May 13, 2022, which was paid for by the Plan. Additionally, the Plan contract states 
that two dental cleanings are covered per year. You previously received this service on February 15, 2022 and 
June 29, 2022, which were paid for by the Plan. Therefore, you have exhausted the allowable benefit for the 
services provided. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120), bitewing x-rays-four radiographic images (D0274), intraoral-periapical first radiographic image 
(D0220), intraoral-periapical additional radiographic image (D0230), and the dental cleaning (D1110) provided 
on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on December 8, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that this procedure was performed to evaluate if there 
was an effect on your eye and reduction of vision as a result of a face/eye injury accident that you suffered. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The record shows that you received a refraction on this date of 
service, and were given a prescription for new glasses. Based on this information, we decided that the Plan's 
rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to 
pay for the eye refraction (92015) provided on December 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from August 30, 2022, to 
August 31, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee meets the criteria for 
admission. The Plan denied your request. The Plan says the request for an inpatient level of care for his 
overnight hospitalization is not medically necessary because the services rendered did not rise to the level of an 
inpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee's diagnosis was elective left heart catheterization with intervention. 
They tolerated the procedure without complication; he required no intervention. The review has determined 
that the record did not show that at the time of inpatient admission the admitting physician reasonably expected 
that the patient's necessary hospital care (including earlier ED and/or observation care) would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services rendered from August 30, 2022, to August 31, 2022.
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 4) provided on October 17, 2022. 
 
You asked the Plan to pay for these 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 the dental services were received from 
an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided are not covered under this benefit when 
received from an out-of-network provider.  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 4) provided on October 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673) provided 
on November 3, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was medically 
necessary. The Plan denied your request. The Plan says the equipment was used outside the home and is not 
covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for a pneumatic compression device (E0675, E0673) provided on November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite-four or more surfaces or 
involving incisal angle (anterior) (D2335) and the pulp cap-indirect (excluding final restoration) (D3120) 
provided on September 14, 2022. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Additionally, the pulp cap dental service is not a covered 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. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the resin-based composite provided. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Additionally, the pulp cap dental service provided is not a covered benefit. 
Therefore, we decided that the Plan does not have to pay more for the resin-based composite-four or more 
surfaces or involving incisal angle (anterior) (D2335) and the pulp cap-indirect (excluding final restoration) 
(D3120) provided on September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery (D6011). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted. Therefore, we decided that the Plan does 
not have to pre-approve surgical access to an implant body (second stage implant surgery (D6011).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the requesting surgical boot is medically 
necessary. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that the enrollee does not suffer from diabetic foot disease, and they do not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Relion Prime test strips. 
 
You asked the Plan to pre-approve Relion Prime test strips. You say that you been using the same monitor and 
testing strips for years. The Plan denied your request. The Plan says only the preferred brand products listed in 
the EOC are covered. 
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for testing strips. Therefore, we decided that the Plan does not have to pre-approve Relion Prime test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental procedure to fix or remove cracked teeth under 
anesthesia. 
 
You asked the Plan to pre-approve a dental procedure to fix or remove cracked teeth under anesthesia. You say 
that this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 pre-approve a 
dental procedure to fix or remove cracked teeth under anesthesia.