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

 
We decided that the Plan does not have to pay for the eyeglass lenses (V2204, V2781, V2203, V2799) 
provided on March 17, 2021. 
 
You asked the Plan to pay for the eyeglass lenses. You say that your benefit covers $250 for these services, and 
you have not used your benefit yet this year. The Plan denied your request. The Plan says this claim was 
processed in accordance with your contract; the Plan has paid $200 for these eyeglasses, and you are 
responsible for the costs that exceed this allowance limit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $200 every year. You are responsible for all costs over and 
above the allowance limit. 
 
We looked at the file and the Plan's rules. The record shows that the full price of the eyeglasses purchased on 
the date in question was $320. The Plan has paid $200, and you are being held responsible for the remaining 
$120. Based on this information, we decided that you have been asked to pay the correct amount based on your 
contract with the Plan. Therefore, we decided that the Plan does not have to pay for the eyeglass lenses (V2204, 
V2781, V2203, V2799) provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two resin-based composites (D2392 x2). 
 
You asked the Plan to pre-approve the resin-based composites. You say that you initially thought you were 
only $629 short in funds to get your fillings taken care of. You also say that you would like the Plan to pay the 
$629 for the fillings, and you would only like to be responsible for the difference. The Plan denied your 
request. The Plan says you have reached the total amount that your plan will pay in a year. 
 
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 total of the two additional resin-
based composites would put you over the annual maximum allowable of $2,000 that is offered for dental 
services. Therefore, we decided that the Plan does not have to pre-approve two resin-based composites (D2392 
x2).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the panoramic x-rays (D0330) and comprehensive periodontal 
evaluation (D0180) provided on July 27, 2021. 
 
You asked the Plan to pay for the panoramic x-rays and comprehensive periodontal evaluation. You say that 
the dental work performed was medically necessary. You also say that without this treatment, your medical 
conditions would further decline. The Plan denied your request. The Plan says that panoramic x-rays are not 
covered. The Plan also says that you have reached your benefit maximum for the time period for the 
comprehensive periodontal evaluation. 
 
Medicare rules say that the health plan must provide you with a clear and accurate description of the Original 
Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including 
applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. 
 
The Plan denied the panoramic x-rays as not being a covered service. The Plan also denied the comprehensive 
periodontal evaluation saying the benefit was exhausted. The 2021 Evidence of Coverage lists panoramic x-
rays and oral exams as covered benefit. The documentation provided does not show that either of these benefits 
have been exhausted. The Plan contract also does not clearly list dental codes for services that are covered by 
the Plan. You reasonably believed these services would be covered, as they are listed as covered dental 
benefits. 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the panoramic x-rays and comprehensive periodontal evaluation have been met. Therefore, we 
decided that the Plan has to pay for the panoramic x-rays (D0330) and comprehensive periodontal evaluation 
(D0180) provided on July 27, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable home ventilator (E0466). 
 
You asked the Plan to pre-approve a portable home ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 portable home ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has 
chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated 
such a device is covered. 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 portable home ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a portable home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December 
19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON dental care. You say that you were told that this was an in-network 
provider. The Plan denied your request. The Plan says out-of-network care is only covered in certain limited 
circumstances. The services at issue were not urgent or emergent and could have been provided in-network. 
The Plan also states they have no records of a call from either you or the provider prior to services. 
 
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 periodontal maintenance (D4910) provided on 
December 19, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 13, 2021. 
 
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 all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a surgical extraction (D7210). 
 
You asked the Plan to pre-approve the dental service. You say that you are in pain. The Plan denied your 
request. The Plan says that a surgical extraction is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not include legible x-rays. Digital quality x-rays were 
requested but none were received. Without legible x-rays, we cannot determine that the service should not be 
approved. Therefore, we decided that the Plan has to pre-approve a surgical extraction (D7210).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis (20610) and injection procedure for contrast 
knee arthrography (27369) provided on August 24, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the arthrocentesis and injection procedure. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says out-of-network 
services were not authorized. 
 
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 arthrocentesis (20610) and injection procedure for 
contrast knee arthrography (27369) provided on August 24, 2021 by an out-of-network (OON) provider.
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 IRF care is the most appropriate setting for the 
enrollee to reach her maximum rehabilitation potential. The Plan denied your request. The Plan says based on 
the documentation submitted, the enrollee would continue to benefit from physical and occupational therapy, 
but the documentation does not support that her functional or medical status requires an intensive rehabilitation 
therapy program or that she requires three hours of therapy a day. Her needs may be met at an alternative level 
of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a user adjustable heel height prosthesis (L5990). 
 
You asked the Plan to pre-approve a user adjustable heel height prosthesis. You say that the requested 
prosthesis 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 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 a user adjustable heel height 
prosthesis (L5990).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on August 
31, 2021. 
 
You asked the Plan to pay for the comprehensive exam. You say that you told your provider that you only 
wanted covered services because you could not pay out-of-pocket. The Plan denied your request. The Plan says 
you had a previous comprehensive oral exam on October 20, 2020. This service is only covered once every 
three years. 
 
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. The Plan covers one 
comprehensive oral exam every 3 plan years. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation supports that the 
comprehensive exam is requested in a frequency that is not covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on August 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlimited routine transportation trips for the enrollee. 
 
You asked the Plan to pre-approve unlimited routine transportation trips. You say that the enrollee requires 
transportation for dialysis appointments. The Plan denied your request. The Plan says that this request exceeds 
the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan does not have to provide routine transportation trips above the benefit maximum of twenty-four 
(24) routine transportation trips.. Therefore, we decided that the Plan does not have to pre-approve unlimited 
routine transportation trips for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit, nor for an 
ambulance transport provided on November 14, 2021.  
 
You asked the Plan to waive the copayment for the emergency room visit and ambulance transportation. You 
say that you do not believe the enrollee should have to pay for these services. The Plan denied your request. 
The Plan says the cost-share was applied 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $90 copayment for Emergency Care and a $275 copayment for Ambulance Services.  
 
The enrollee has been asked to pay a $365 copayment for an emergency room visit ($90 copayment) and 
ambulance transport ($275 copayment) ($90 + $275 = $365 copayment). The services at issue fall within the 
Emergency Care and Ambulance Services benefit categories. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an emergency room visit and an ambulance transport provided on November 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered equipment charges provided on November 10, 2020. 
 
You asked the Plan to pay for non-covered equipment charges. You say that you submitted this claim in a 
timely manner. The Plan denied your request. The Plan says the denial of payment for this charge is correct. 
The Plan also says that they have approved payment for the seat lift mechanism itself. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This code represents the non-covered charges associated with the lift chair. Therefore, we decided that the Plan does not 
have to pay for non-covered equipment charges provided on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220), and bitewing x-rays (D0274) 
provided on November 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that it has been many years since you had x-rays 
done. You also say that it seems that quality dental care would require an x-ray. The Plan denied your request. 
The Plan says dental x-rays are not listed as covered. 
 
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 dental x-rays are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray 
(D0220), and bitewing x-rays (D0274) provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 16, 2021. 
 
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 all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right lower limb prosthetic components (prosthetic 
codes L5828, L5845, L5848, L5850, L5856). 
 
You asked the Plan to pre-approve lower limb prosthetic components. You say that this is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the denial of authorization for these items is 
correct, because the arguments do not offer reasons why a mechanical knee would not meet the enrollee's 
needs. 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 lower limb prosthetic components. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Plan has already approved a K3 level prosthesis and there is no 
documentation to indicate the reason why a mechanical knee is not appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic components have not been met. Therefore, we decided 
that the Plan does not have to pre-approve right lower limb prosthetic components (prosthetic codes L5828, 
L5845, L5848, L5850, L5856).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) purchased November 8, 2021 from 
an out of network provider. 
 
You asked the Plan to pay for the hearing aids. You say that you had purchased hearing aids for in 2020 from 
this provider and assumed they were still on the vendor list. The Plan denied your request. The Plan says 
enrollees must receive their hearing services from an in-network provider 
 
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 purchased from an in network vendor.  
 
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 aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5298) purchased November 8, 2021 from an out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206 and 81292) provided on July 
25, 2021. 
 
You asked the Plan to pay for codes 81206 and 81292. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206 and 81292) provided on July 25, 2021.