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

 
We decided that the Plan does not have to pay for fundus photography and frames and/or lens provided on 
September 19, 2022. 
 You asked the Plan to pay for fundus photography and frames and/or lens. You say that you paid the $39. You 
also say you overpaid them, and tried to contact the insurance. The Plan denied your request. The Plan says the 
fundus photography is not covered by the plan. The Plan also says that you are responsible for any amount over 
the $500 allowance. 
 
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 a $500 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses (1 per calendar year). Fundus photography is excluded from this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $500 benefit toward the purchase and 
fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). Fundus photography is excluded 
from this benefit. Based on this information, we decided that the Plan's rules for coverage of fundus 
photography and frames and/or lens have not been met. Therefore, we decided that the Plan does not have to 
pay for fundus photography and frames and/or lens provided on September 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered. The Plan 
denied your request. The Plan says a primary Evidence of Benefits (EOB) was not received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has notified the 
provider of the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the laboratory 
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for the laboratory services provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the cervical spine (72040) provided on 
January 25, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the x-ray exam of the cervical spine (72040) provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device. 
 
You asked the Plan to pre-approve the requested device. You say that a new machine would adjust breathing 
patterns as needed. The Plan denied your request. The Plan says your current machine is working properly. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a CPAP device. Your current device serves the same purpose as the requested 
device. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure 
(CPAP) device.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on August 16, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the diagnosis is valid for the visit. The Plan 
denied your request. The Plan says the claim was correctly denied. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 90791 was billed with diagnosis code F06.32, mood disorder due to known 
physiological condition with major depressive-like episode. Diagnosis code section F06 for mental disorders 
due to known physiological conditions has a code first note indicating sequencing rules apply. 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 the outpatient mental health services provided on August 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) visit provided on May 18, 
2022. 
 
You asked the Plan to pay for a skilled nursing facility (SNF) visit. You say that the services does not require 
prior authorization. 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 a skilled nursing facility 
(SNF) visit provided on May 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary for 
follow-up on your care. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for admission to 
an LTACH. You do not require services at the LTACH that are not available at the acute care hospital where 
you are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient 
basis. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at an alternate 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 enrollee does not have any complex functional deficits or active medical 
issues. The enrollee's needs do 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for a limited oral evaluation (D0140) and treatment of root canal 
(D3331) for tooth #8. We decided that the Plan does not have to pay for cone beam (D0367) and unlisted 
service (99199).  You asked the Plan to pay for a limited oral evaluation (D0140), cone beam (D0367), treatment of root canal 
(D3331), and unlisted service (99199) for tooth #8 provided on March 29, 2022, June 3, 2022, and July 21, 
2022.. You say that you fell, and the dental services were necessary. The Plan says that the dental services were 
not medically necessary. 
 
We decided that the Plan has to pay for a limited oral evaluation (D0140) and treatment of root canal 
(D3331) for tooth #8.  
 
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 Plan covers limited oral 
evaluations and treatment of root canals when the services are medically necessary and reasonable. 
 
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 the dental services. Our reviewer says that 
the limited oral evaluation and treatment of root canal were medically necessary. Our physician reviewer found 
that the documentation indicates that the patient sustained trauma to the face in teeth resulting from a fall. An 
oral examination revealed that tooth #8 lost its vitality and the pulpal tissue was necrotic. A root canal was 
required to maintain this tooth in the arch.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the limited oral evaluation and treatment of root canal have been met. 
Therefore, we decided that the Plan has to pay for a limited oral evaluation (D0140) and treatment of root canal 
(D3331) for tooth #8.  
 
We also decided that the Plan does not have to pay for cone beam (D0367) and unlisted service (99199). 
 
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 cone beam and unlisted service are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
cone beam (D0367) and unlisted service (99199). 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on August 5, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were admitted to the hospital this 
day, and to process this under your drug plan. The Plan denied your request. The Plan says self-administered 
drugs are covered under the pharmacy benefit. 
 
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 pay for the self-administered drugs 
provided on August 5, 2022.  
 Benefits for the self-administered drugs 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 pay for the outpatient foot surgery (2999), provided on March 10, 
2022. 
 
You asked the Plan to pay for the outpatient foot surgery. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the service was not medically necessary. 
 
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 pay for the outpatient foot surgery. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of conservative measures to include show medications, injections, 
and toe taping for foot pain treatment. More conservative measures are needed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the outpatient foot surgery have not been met. Therefore, we decided that the 
Plan does not have to pay for the outpatient foot surgery (2999), provided on March 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0650). 
 
You asked the Plan to pay for a back brace. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that if a spinal orthosis is provided and the coverage 
criteria are not met, the item will be denied as not medically necessary.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a back brace. Our reviewer says that this 
item is not medically necessary. Our physician reviewer found this item is not being used to reduce pain by 
restricting mobility of the trunk. This item is not being used to facilitate healing following an injury to the spine 
or related soft tissues; or to facilitate healing following a surgical procedure on the spine or related soft tissue; 
or to otherwise support weak spinal muscles and/or a deformed spine. 
 
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 back brace have not been met. Therefore, we decided that the Plan does not 
have to pay for a back brace (L0650).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on July 27, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound provided on July 27, 2022. You say that when 
you signed up for your health plan were told x-rays and ultrasounds were covered. You would like the cost 
share to be reconsidered. 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 $165 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). 
  You have been asked to pay $120.14, which is less than the standard $165 copayment for an ultrasound. This 
item/service falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound provided on July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's acute needs have been met 
and stabilized in the acute care setting. You say that the enrollee is stable and ready for transfer to an LTACH 
for continuation of care. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee can receive the care they need in the current hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The health plan has approved ongoing care in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) visit provided on October 12, 
2022. 
 
You asked the Plan to pay for a skilled nursing facility (SNF) visit. You say that the records attached support 
the services provided. 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 a skilled nursing facility 
(SNF) visit provided on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take home supply of methadone (G2078), provided on 
September 26, 2022. 
 
You asked the Plan to pay for the take home supply of methadone. You say that this was medically necessary. 
The Plan denied your request. The Plan says this is not covered. 
 
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 the 
take home supply of methadone is an add-on code and has not been billed with an appropriate primary 
procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the take home supply of methadone (G2078), provided on 
September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on September 09, 
2022. 
 
You asked the Plan to waive the copayment for office visit. 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 $35 
copayment for physician/practitoner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for office visit. This item/service falls within the 
physician/practitoner services, including doctors 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. Therefore, we decided that the Plan does not have 
to waive the copayment for office visit provided on September 09, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee's tremor prohibits regular 
fingerstick monitoring. The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.