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

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on July 6, 2021. 
 You asked the Plan to pay for the eye refraction. You say that you paid your $30 specialist visit copay and 
should not have to pay extra for this service. The Plan denied your request. The Plan says eye refractions are 
not covered by Medicare. This service was not received from a provider in the specified routine vision network. 
Therefore, payment will not be made. 
 
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 eye refractions when they are received as part of a routine (non-medical) eye exam 
and are performed by a provider within the Plan?s specified routine vision vendor network. 
 
We looked at the file and the Plan's rules. The eye refraction in this case was not received as part of a routine 
eye exam from a provider in the specified network. Based on this information, we decided that the Plan's rules 
for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay 
for the eye refraction (92015) provided on July 6, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on May 11, 2021, through 
May 13, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration 
because this inpatient hospital services were medically necessary. The Plan denied your request. The Plan says 
that there is insufficient documentation to support that the inpatient hospital care was 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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably 
expected that your necessary hospital care (including earlier ED and/or observation care) would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on May 11, 2021, through May 13, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on July 12, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab tests. You say that when the enrollee was switching from Original Medicare, 
they were expecting to receive the same level of coverage. The Plan denied your request. The Plan says the 
denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the 
ordering provider is also out-of-network with the Plan. 
 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 laboratory testing provided on July 12, 2021 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on February 15, 2021, and 
February 18, 2021. 
 
You asked the Plan to pay for the dental care. You say that these services were necessary and should be 
covered. The Plan denied your request. The Plan says they have agreed to process your claims for dental 
services as in-network, as there is no way you could have known which tax identification number your provider 
would use on the bill. The Plan has made an exception in this case for the care. However, you met your $1,000 
annual maximum between these two claims, and additional payment for dental care will not be made. 
 
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 will pay a maximum 
of $1,000 per year for covered dental care. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, items or services that exceed the 
$1,000 annual maximum are not covered. In addition, only the services listed in the Plan?s contract are eligible 
for payment up to the annual maximum. Documentation shows that the Plan has paid the full $1,000 allowed 
for covered supplemental dental care in 2021. Therefore, we decided that the Plan does not have to pay for the 
dental services provided on February 15, 2021, and February 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from December 30, 2020, to January 12, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you did not think 
there would be a copayment since this admission was due to COVID-19. The Plan denied your request. The 
Plan says this copayment was charged correctly.  The Plan says that their copayment waiver for COVID-19-
related treatment was only in effect until June 30, 2020. 
 
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 $225 
copayment per day for days 1-7, and a $0 copayment for days 8-90 for inpatient hospital care.  
 Records show you were in the hospital for 14 days.  You were charged a $225 copayment per day for the first 7 
days, for a total of $1575. You have been asked to pay a $225 copayment per day for days 1-7, and a $0 
copayment for days 8-90 for the inpatient hospital services. 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 inpatient hospital services you received from December 30, 2020, to January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 16, 2020 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab tests. You say that there was not an in-network provider that could offer the 
necessary service. The Plan denied your request. The Plan says the denial of payment for this testing is correct, 
because this provider is out-of-network with the Plan and authorization was not obtained.   
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 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 laboratory testing provided on May 16, 2020 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventative procedure (D1999) (COVID-19 
protection fee) provided on July 12, 2021. 
 
You asked the Plan to pay for the unspecified preventative service. You say that you thought this fee would be 
covered by the Plan until July 2021. The Plan denied your request. The Plan says that they were waiving the 
fee for this service, but that provision ended on June 30, 2021. 
 
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 
unspecified preventative procedure (D1999) (COVID-19 protection fee) provided on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 32120, 32654) provided 
to the enrollee on May 18, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 the denied code is: 
 
CPT 32120: 
 
Thoracotomy; for postoperative complications 
 
We find that CPT code 32120 is not supported in the medical record. Specifically, the use of modifier 78 in this 
case is not supported. This modifier is used to indicate an unplanned return to the operating/procedure room, by 
the same physician as the initial procedure. However, there is no evidence of an initial previous surgical procedure that would support using this modifier. 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 
surgical services (procedure codes 32120, 32654) provided to the enrollee on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on July 2, 2021. 
 
You asked the Plan to pay for the occlusal guard. You say that this appliance helps your migraines and should 
be covered under your medical benefit. The Plan denied your request. The Plan says there is no evidence that 
the requested occlusal guard is approved for treatment of migraines. This service is not covered by Medicare or 
by your dental benefit. 
 
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. Medicare rules also 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 D9944 is a removable dental appliance designed to 
minimize the effects of bruxism or other occlusal factors. Not to be reported for any type of sleep apnea, 
snoring or temporomandibular disorders (TMD) appliances. We find that CPT code D9944 is not supported as 
a medical appliance for migraines and is only to be billed as a dental appliance for the treatment of bruxism 
(grinding or clenching of teeth) or other dental-related factors. Therefore, the service billed is a dental 
appliance and not covered by the medical benefit. The Plan?s contract also states that occlusal guards are not 
covered. 
 
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 
occlusal guard (D9944) provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital visit with laboratory 
services provided on May 21, 2021. 
 
You asked the Plan to waive the copayment for the visit and laboratory services. You say that you have never 
had to pay this fee before. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing 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 $395 
copayment for each non-surgical outpatient hospital visit after you meet your $395 deductible.  
 
You have been asked to pay $143.97, which is less than the $395 copayment for the visit and laboratory services. The visit and laboratory services fall within the Outpatient Hospital 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 outpatient hospital visit with laboratory services 
provided on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from May 28, 2021, to June 2, 
2021, with an out-of-network dentist. 
 
You asked the Plan to pay for the out-of-network dental services. You say that you needed to have dental 
clearance for a cardiac procedure.  You stated that network dentists were not available, so you went to an out-
of-network dentist. The Plan denied your request. The Plan says dental care with out-of-network providers is 
not covered. In addition, there is no evidence that you contacted the Plan for assistance in locating an in-
network provider. 
 
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 dental 
services you received from May 28, 2021, to June 2, 2021, with an out-of-network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoride application (D1206), the drugs (D9630), the 
extra quadrants of periodontal scaling and root planing (D4341 and D4342), the oral hygiene instruction 
(D1330), the unspecified periodontal procedures (D4999), and the extra quadrants of gingival irrigation 
(D4921). 
 
You asked the Plan to pay for the dental services. You say that you don't understand how this claim was 
processed. The Plan denied your request. The Plan says these services are not covered under your dental 
benefit. 
 
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. Specifically, dental codes D1206, D9630, D1330, D4999, and D4921 
are not listed among the Plan's covered dental benefits.  For the periodontal scaling and root planing services, 
you are only covered for 1 quadrant every 2 years.  For the gingival irrigation, you are only covered for 1 
quadrant every calendar year.  For both of these services, you received services beyond what is allowed in your 
contract, so the extra units of these services are not covered. Therefore, we decided that the Plan does not have 
to pay for the fluoride application (D1206), the drugs (D9630), the extra quadrants of periodontal scaling and 
root planing (D4341 and D4342), the oral hygiene instruction (D1330), the unspecified periodontal procedures 
(D4999), and the extra quadrants of gingival irrigation (D4921).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One (J7325). 
 
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Synvisc-One. Our reviewer says that 
Synvisc-One (J7325) is not medically reasonable and necessary for the enrollee. Our physician reviewer found 
the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as 
outlined by the Plan, requires that these be trialed first. Our reviewer found that the documentation does not 
outline contraindications or reasons these medications were not considered or that the Plan?s additional 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Our physician 
reviewer also found that without the support of the documentation, Synvisc-One is not approved, as step 
criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One (J7325).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits to monitor your blood 
pressure. 
 
You asked the Plan to pre-approve home health skilled nursing visits. You say that you need help in your home 
with your blood pressure. The Plan denied your request. The Plan says you do not meet Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health skilled nursing visits to monitor your blood pressure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the outpatient surgery provided from June 
28, 2021, through July 2, 2021. 
 
You asked the Plan to reduce the coinsurance for the outpatient surgery. You say that your wife also had 
surgery at this same facility, and it did not cost as much as yours. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing 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 20% 
coinsurance for surgery performed at an outpatient hospital facility.  
 
You have been asked to pay $6,197.78, which is 20% of the allowed amount for the outpatient surgery 
($30,988.92 allowed amount x 20% coinsurance = $6,197.78). The outpatient surgery 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 reduce the coinsurance for the outpatient surgery 
provided from June 28, 2021, through July 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan 
denied your request. The Plan says this service is covered under the benefit package, but the request exceeds 
the maximum count allowed per period. 
 
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 Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (code D5110) you received 
on May 11, 2021. 
 
You asked the Plan to pay for the complete maxillary denture. You say that you were told that you would have 
dental coverage that includes dentures.  You stated that you are low income and you needed to borrow money 
to pay for this. The Plan denied your request. The Plan says this service is not covered under your dental 
benefits. 
 
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 
complete maxillary denture (code D5110) you received on May 11, 2021.