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

 
We decided that the Plan does not have to pay for a computerized corneal topography (92025) provided on 
June 21, 2022. 
 
You asked the Plan to pay for a computerized corneal topography (92025). You say that these services were 
necessary for a medical visit for cataract surgery. The Plan denied your request. The Plan says because the 
provider is out-of-network with the members plan and because there is no coverage when services are rendered by a non-par provider, the Plan as well as plan's vision benefit will maintain its initial determination to 
not pay for the submitted claim. 
 
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 when they are received at an in-network optical provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that any benefits received at a non-network optical 
provider are excluded from the vision benefit. The record shows that this provider is not in-network with the 
plan vision benefit. Based on this information, we decided that the Plan's rules for coverage of a computerized 
corneal topography (92025) have not been met. Therefore, we decided that the Plan does not have to pay for a 
computerized corneal topography (92025) provided on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intra-oral x-ray (D0210) provided on August 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 on date of service February 11, 2022. 
Therefore, we decided that the Plan does not have to pay for an intra-oral x-ray (D0210) provided on August 5, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) 
provided on September 21, 2022. 
 
You asked the Plan to pay for this dental 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 May 6, 2022. Specifically, the 
Plan provides coverage of one limited oral evaluation per year. You previously received this service on May 6, 
2022, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation-problem focused 
(D0140) provided on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services 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 dental services on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 15, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 an office visit provided 
on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 25, 2022. 
 
You asked the Plan to pay for an office visit. You say that you were not aware your doctor was not in-network. 
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 an office visit provided 
on July 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ketorolac tromethamine. 
 
You asked the Plan to pre-approve Ketorolac tromethamine. You say that the services are 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 Ketorolac tromethamine.  
 
Benefits for Ketorolac tromethamine 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on September 
14, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you want to appeal the amount 
being charged 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 $150 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $150 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery provided on 
September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service July 6, 2022. 
 You asked the Plan to pay for procedure code 81345. You say that these services were necessary and are 
supported in the medical records. The Plan denied your request. The Plan says payment for code 81345 is 
bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service July 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The services at issue are a power seat elevation feature. This item is 
not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met. 
 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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found while the enrollee is being assessed 
for atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation 
to support the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on March 
11, 2022, to June 06, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that this should be covered. 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 $25 
copayment for Specialist office visits. 
 
You have been asked to pay a $25 copayment for specialist office visits. This item/service falls within the 
Specialist 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. You have been asked to pay $50 ($25 x 2 visits) copayment for your specialist office 
visits. Therefore, we decided that the Plan does not have to waive the copayment for specialist office visits 
provided on March 11, 2022, to June 06, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), although there are 
no pulmonary function tests. Other diagnoses include severe obesity, obesity hypoventilation syndrome (OHS), 
obstructive sleep apnea (OSA) not on continuous positive airway pressure (CPAP). There is a history of lung 
resection for lung cancer followed by radiation. This enrollee has been hospitalized twice in the last month with acute on chronic hypercarbic respiratory failure. Each time has improved on bilevel positive airway pressure 
(BiPAP). The enrollee may benefit from BiPAP with average volume-assured pressure support (AVAPS) 
during sleep. There is no documentation that this has been tried and failed. Medicare does not cover a home 
ventilator when used as 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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services 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 dental services provided on May 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to approve a SNF admission and services.  
 
You asked the Plan to approve a skilled nursing facility (SNF) admission and services. You say that you are 
familiar with this facility and wish to remain in this community. The Plan denied your request. The Plan says a 
SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
 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 approve a SNF admission and services. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. you do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 a SNF admission and services have not been met. Therefore, we decided that 
the Plan does not have to approve a skilled nursing facility (SNF) admission and services. a Skilled Nursing 
Facility (SNF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $290 copayment for outpatient surgery for diagnostic 
colonoscopy. 
 
You asked the Plan to waive the $290 copayment for outpatient surgery. You say that you shouldn't have to pay 
the copayment due to nothing surgical was done. 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 $290 
copayment for colorectal cancer screening.  
 
You have been asked to pay a $290 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery benefit category on page 107. The Plan contract also states a diagnostic colonoscopy is 
performed in order to explain symptoms identified by your physician (for example, blood in stools, change in 
bowel movements, iron deficiency due to anemia, persistent abdominal pain, etc.), because youve had a 
previous colonoscopy that resulted in removal of polyps, or other colorectal related conditions. If your 
physician orders a diagnostic colonoscopy the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers copayment applies. You can find this information on page 
76. 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 $290 copayment for outpatient surgery for diagnostic colonoscopy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the bone scan provided on August 10, 
2022. 
 
You asked the Plan to waive the copayment for the bone scan. You say that this service was covered on your 
last bill for the same service. 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 $100 
copayment for basic radiological services provided in an outpatient hospital setting.  
 
You have been asked to pay $88.12 for the bone scan, which is less than your copayment. This item/service 
falls within the basic radiological services provided in an outpatient hospital setting 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 bone scan provided on August 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for inpatient hospital services provided on July 
9, 2022. 
 
You asked the Plan to waive the deductible for inpatient hospital services. You say that you don't believe you 
have to pay for this service because you never have 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. Your 
contract with the Plan says that there is a $300 deductible per calendar year for covered services received in a 
general acute care hospital.  
 
The item or service you asked the Plan to waive the deductible for falls within the inpatient hospital care 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 
deductible for inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the 
time inpatient hospital services was received on July 9, 2022. Therefore, we decided that the Plan does not have 
to waive the deductible for inpatient hospital services provided on July 9, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service May 23, 
2022. You asked the Plan to pay for procedure code 97010. The Plan denied your request. The Plan says procedure 
code 97010 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
97010 billed for date of service May 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services rendered on August 9, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that intraoperative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. The file shows that procedure code J3490 was related to and billed on 
the same day as surgical procedure 27096. Payment for code J3490 is included in the global surgical package. 
Therefore, we decided that the Plan does not have to pay for the drug services rendered on August 9, 2022.