Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses provided on April 8, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that you were not informed of any stipulations that 
denies coverage for eyecare. You say that you want to appeal for reimbursement. The Plan denied your request. 
The Plan says the services were provided before the allotted 1-year benefit reset.  
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 up to $150 toward the cost of routine contact lenses or eyewear every year. This 
benefit is administered on a rolling calendar year since your last date of service. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Specifically, your previous pair of eyeglasses were purchased on 
December 26, 2020 and these eyeglasses were purchased prior to the 1-year benefit reset. Therefore, we 
decided that the Plan does not have to pay for the eyeglasses provided on April 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on August 21, 2020. 
 
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers. You 
say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says the records do not support the service billed. 
  
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on August 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 14, 2021. 
 
You asked the Plan to pay for the services provided. You say that the treatment was medically necessary. The 
Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment 
testing screening panels for suspected or documented cardiovascular disease. 
 
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. 
 
We looked at the file and the rules. The records show that the enrollee requested genetic testing to determine 
whether she has a gene mutation. The testing was requested solely for screening purposes. Medicare does not 
cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit you had on June 8, 2021. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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. Therefore, we decided that 
the Plan does not have to pay for the chiropractic office visit you had on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on June 15, 2021. 
 
You asked the Plan to pay for the refraction. You say that whatever test they feel is necessary should be 
covered by insurance. The Plan denied your request. The Plan says eye refractions are only covered with a 
routine vision screening when performed by a Plan provider. 
  
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 this service when it is performed with a routine vision exam by a Plan provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the refraction have not been met. Specifically, the refraction was performed with a medical eye 
exam. Therefore, we decided that the Plan does not have to pay for the refraction provided on June 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-invasive arterial study you received 
on April 14, 2021. 
 
You asked the Plan to waive the copayment for the non-invasive arterial study. You say that this procedure 
should be covered by the Plan. The Plan denied your request. The Plan says the Plan says that you were 
charged this copayment correctly.  The Plan says that because the allowed rate for this procedure ($85.05) is 
less than your copayment obligation, you are responsible for the full allowed 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 $155 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $155 copayment for the non-invasive arterial study. The non-invasive arterial 
study falls within the radiological diagnostic 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 the non-invasive arterial study you received on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
9, 2021. 
 
You asked the Plan to pay for the dental service. You say that there is no cost for evaluations and cleanings 
whether in or out of network. You say that the services were originally covered under a different plan. You also 
say that you feel this was denied in error. The Plan denied your request. The Plan says 1 comprehensive oral 
evaluation is covered every 3 years. The Plan also says that the frequency limit has been exceeded. 
 
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 the dental service have not been met. Specifically, the frequency limit has been exceeded. The 
record shows that the Plan paid for a comprehensive oral evaluation that you received on March 11, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on June 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary due to 
quality of life. The Plan denied your request. The Plan says that records do not show that the enrollee requires 
daily skilled services that can only be provided on an inpatient basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve a continuation of SNF care. You say that the records provided support the 
need for continued SNF care. The Plan denied your request. The Plan says the enrollee does not have any daily 
skilled complex nursing or therapy needs. The plan says that while the enrollee may benefit from continuing 
physical, occupational, and speech therapy, the records do not support the need for daily therapy on an 
inpatient basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of 
admission, the enrollee required skilled rehab services to improve function due to weakness and 
deconditioning.  There were no skilled nursing needs. As of November 7, 2021, the enrollee did not require any 
skilled nursing or rehab services on a daily basis.  She was not expected to make measurable gains within a 
reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or 
activities of daily living. The enrollee did not require skilled therapy to establish a safe and effective 
maintenance program.  As a practical matter, the enrollee did not require any skilled services on an inpatient 
basis, at a SNF level of care as of November 7, 2021. The enrollee did not have any parental medications, 
complex wound care or nutrition given via a feeding tube.  The enrollee received skilled care and improved; 
however, her function had plateaued by November 7, 2021, and she did not require any further inpatient skilled 
rehabilitation services. The enrollee's function was at or near her prior level of function and she could be 
discharged to a lower level of care for further services.  As of November 7, 2021, the enrollee required 
custodial services. 
 
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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you require the foot orthotics. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) 
you had at an ambulatory surgical facility on May 7, 2021. 
 
You asked the Plan to waive the copayment for the EGD. You say that you believe this should be covered at 
100%. The Plan denied your request. The Plan says you were charged this copayment 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 $395 
copayment for outpatient surgery.  
 
You have been asked to pay a $395 copayment for the EGD. The EGD falls within the outpatient surgery 
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 
esophagogastroduodenoscopy (EGD) you had at an ambulatory surgical facility on May 7, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 
8, 2021. 
 
You asked the Plan to pay for the dental service. You say that due to the circumstances, this service should be 
covered. You also say that you were not able to go back to your regular dentist to have them do the exam. The 
Plan denied your request. The Plan says 1 oral evaluation is covered every calendar year. The Plan also says 
that the frequency limit has been exceeded. 
 
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 and the services is listed as covered, the 
frequency limit has been exceeded. The record shows that the Plan paid for the comprehensive oral evaluation 
that you received on March 23, 2021. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), provided on May 5, 
2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you were not aware the service was 
not 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 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 
periodontal maintenance (D4910), provided on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on May 18, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no 
documentation of consultation with the attending or primary care physician in the patient's medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP must attempt to consult with the patient's 
physician within a reasonable time after receiving the consent. If the CP's attempts to consult directly with the 
physician are not successful, the CP must notify the physician within a reasonable time that he or she is 
furnishing services to the patient.  
 
We looked at the file and Medicare rules. The records provided do not show that the CP consulted the 
enrollee's PCP/attending. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient mental 
health services provided on May 18, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve endovascular repair of infrarenal aorta by deployment of an aorto-
aortic tube endograft. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that the member is asymptomatic, and the aneurysm is not 
expanding. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. The patient has an 
abdominal aortic aneurysm (AAA) noted on both abdominal duplex in the computed tomography angiography 
(CTA). By CTA, the aneurysm is infrarenal and measures 5.4 cm in diameter. This is within the margin of error 
for measurement of the 5.5 cm threshold noted in the coverage criteria. For all intents and purposes, this is a 
5.5 cm (a difference of a millimeter) abdominal aortic aneurysm and repair is both reasonable and medically 
necessary. Our physician reviewer found that the enrollee's condition meets criteria for coverage of these 
services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft.  
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance, advanced life support (ALS), 
transport (A0426) provided on June 2, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you were treated but were not transported to 
the emergency room. You also say that you were treated at the scene for lack on insulin. The Plan denied your 
request. The Plan says there was no transportation provided. The Plan also says that ambulance response with 
no transport is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 2, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance, advanced life 
support (ALS), transport (A0426) provided on June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee brace billed with CPT code A4467 and provided on 
April 12, 2021. 
 
You asked the Plan to pay for the knee brace. You say that you would like reconsideration because the knee 
brace was provided as part of your physical therapy. The Plan denied your request. The Plan says the submitted 
procedure code is not covered per CMS and would not fall under your Durable Medical Equipment coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code A4467 is belt, strap, sleeve, garment, or covering, any 
type. 
 
We find that CPT code A4467 is not supported in the record. Specifically, per CMS, CPT code A4467 has a 
status indicator of N. This means that CPT code A4467 is non-covered. Based on this information, we decided 
that Medicare rules for coverage of the knee brace have not been met. Therefore, we decided that the Plan does 
not have to pay for the knee brace billed with CPT code A4467 and provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for an office visit and eyeglasses provided 
on March 4, 2021. 
 
You asked the Plan to pay an additional amount for an office visit and eyeglasses. The Plan denied your 
request. The Plan says the office visit is not a covered service under your routine vision plan and your 
responsibility for that service would be $60. Your responsibility for the frame and lens services was $223.96 
after the benefits were applied making the total amount owed to the provider $283.96. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services with a $100 (combined in and out-of-network) benefit toward the purchase and fitting of 
eyeglasses and pair of lenses or contact lenses (1 per calendar year). 
 
We looked at the file and the Plan's rules. The file shows that the Plan paid the correct amount for the 
eyeglasses and the office visit is not covered under the routine vision benefit. Therefore, we decided that the 
Plan does not have to pay an additional amount for an office visit and eyeglasses provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle placement services provided on May 11, 2021. 
 
You asked the Plan to pay for the services provided. You say that separate procedures were performed. The 
Plan denied your request. The Plan says no separate payment is made. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 36000 is introduction of needle or intracatheter into a 
vein. We find that CPT code 36000 is a bundled code. When these services are covered, payment for them is 
subsumed by the payment for the services to which they are incident. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the needle placement services provided on May 11, 2021