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

 
We decided that the Plan does not have to waive the copayment for eye exam provided on July 07, 2022. 
 
You asked the Plan to waive the copayment for eye exam. 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 $35 
copayment for Eye exam. 
 
You have been asked to pay a $35 copayment for eye exam. This item/service falls within the Eye exam 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 $27.58 which is less than the standard $35 copayment for an eye exam. Therefore, we decided that 
the Plan does not have to waive the copayment for eye exam provided on July 07, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan drops. 
 
You asked the Plan to pre-approve Rocklatan drops. You say that the enrollee has a strong family history of 
glaucoma. You say that they have suffered injuries from shrapnel to the face. You also say that you do not want 
to delay treatment. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
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 Rocklatan drops.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid provided on March 2, 2022. 
 
You asked the Plan to pay for the hearing aid. You say that you were told the enrollee had a $500 maximum 
allowance towards hearing aid devices from a network provider. You say you are a network provider. The Plan 
denied your request. The Plan says the provider was out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when hearing aids are provided by network providers. 
 
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 hearing aid have not been met. Specifically, you are not a network provider. Therefore, we 
decided that the Plan does not have to pay for the hearing aid provided on March 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care would place the enrollee at risk 
for complications. The Plan denied your request. The Plan says the enrollee would not be able to tolerate 
intensive therapies. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for sepsis and pyelonephritis. His medical problems are 
stable. The complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required tooth #5 
(D2950). 
 
You asked the Plan to pre-approve the core buildup, including any pins when required tooth #5 (D2950). You 
say that the core build-up will be necessary for the retention of the crown, and this would be an endodontically 
treated tooth. 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 pre-approve core 
buildup, including any pins when required tooth #5 (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the provider would like to follow up after 
surgery. The Plan denied your request. The Plan says network providers are available to provide necessary 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on August 08, 2022. 
 
You asked the Plan to pay for mental health services. You say that you were told by the Plan that they would 
reimburse you for this service. 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 mental health services 
provided on August 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit by the Plan or by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation of an established patient (D0120) 
and implant maintenance procedures when prostheses are removed and reinserted, including cleansing of 
prostheses and abutments (D6080) provided on August 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says the cost sharing was charged correctly, and one service is not a covered benefit 
under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, D6080 is not among those covered 
under this benefit. Additionally, the cost share for D0120 was charged correctly. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation of an established patient (D0120) and implant 
maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and 
abutments (D6080) provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from June 18, 2022, to October 
10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed your provider was out-
of-network. 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 provided from June 18, 2022, to October 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from June 1, 2022, to June 24, 2022. 
 
You asked the Plan to waive the copayment for the skilled nursing facility (SNF) care. You say that the bill 
should have been sent to the VA. 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 $80 per 
day for days 21-100 for skilled nursing facility (SNF) care.  
 
 
  The file shows that you were in the skilled nursing facility for 31 days from May 24, 2022, to June 24, 2022. 
Since there is no copayment for the discharge date, you have been asked to pay $80 per day for days 21-30 for 
the skilled nursing facility (SNF) care. The total for your stay is $880. This item/service falls within the skilled 
nursing facility (SNF) care 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 skilled 
nursing facility (SNF) care provided from June 1, 2022, to June 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a specialist visit. You say that seeing the requested provider for follow-up 
on your condition is medically necessary. The Plan denied your request. The Plan says services requested can 
be provided by an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214), and complete 
denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the mandibular partial denture (D5214), and complete denture - maxillary 
(D5110). You say that you are wanting to have your teeth pulled out because they were non-existent and 
because of infections in your gums. You also say you want dentures and a partial. The Plan denied your 
request. The Plan says these services are 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 pre-approve a 
mandibular partial denture (D5214), and complete denture - maxillary (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring of condition provided on May 20, 2022. 
 
You asked the Plan to pay for remote monitoring of condition. 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 remote monitoring of 
condition provided on May 20, 2022.
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 [Enter appellant's argument from appeal letter, 
e.g. "...you need SNF care."] 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 pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on April 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The records show that the services at issue were reimbursed by the 
Plan on July 19, 2022. The claim lines at issue are exact duplicates. There is no evidence to support that the 
billed /services were provided twice on the same date. Based on this information, we decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the 
radiology services provided on April 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetes risk panel testing provided on January 31, 2022. 
 
You asked the Plan to pay for the panel testing. The Plan denied your request. The Plan says one code must be 
submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the diabetes risk panel testing provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osseous surgery for all quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing 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 April 03, 2019, and May 
29, 2019. Therefore, we decided that the Plan does not have to pre-approve an osseous surgery for all 
quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the intraoral-periapical first radiographic 
image (D0220), intraoral-periapical each additional radiographic image (D0230), limited oral evaluation-
problem focused (D0140), the extraction, of an erupted tooth requiring removal of bone and/or sectioning of 
tooth (D7210), bone graft at the time of the implant placement (D6104), surgical placement of implant body: 
endosteal implant (D6010), the custom fabricated abutmentincludes placement (D6057), and the abutment 
supported porcelain fused to metal crown (high noble metal) (D6059) rendered by the out-of-network (OON) 
provider from April 12, 2022, through July 26, 2022. 
 
You asked the Plan to issue reimbursement for these items/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 services are 
not payable as they were rendered by an out-of-network provider.  
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 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 
items/services 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 issue reimbursement for the intraoral-periapical first 
radiographic image (D0220), intraoral-periapical each additional radiographic image (D0230), limited oral 
evaluation-problem focused (D0140), the extraction, of an erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210), bone graft at time of implant placement (D6104), surgical placement of implant 
body: endosteal implant (D6010), the custom fabricated abutmentincludes placement (D6057), and the 
abutment supported porcelain fused to metal crown (high noble metal) (D6059) rendered by the out-of-network 
(OON) provider from April 12, 2022, through July 26, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 28, 2022, through 
July 28, 2022. 
 
You asked the Plan to pay for these services. You say that the acute inpatient hospital admission was medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the acute inpatient hospital 
admission was not medically necessary. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was hospitalized on June 28, 2022 with acute mental status changes, septic shock and 
kidney failure. He also underwent a procedure on the gallbladder. Additionally, the enrollee underwent a 
procedure on July 12, 2022 to revise his dialysis access and placement of an inferior vena cava filter. The 
review indicates that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from June 28, 2022, through July 28, 2022.  
 
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.