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

 
We decided that the Plan does not have to pay in the full amount for a limited oral evaluation (D0140), 
periapical x-rays (D0220, D0230), and a pulp vitality test (D0460) provided on April 27, 2022. 
 You asked the Plan to pay in the full amount for the dental services. You say that you were told the provider 
was in-network. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. The Plan also says that a pulp vitality test is not covered by your Plan's dental benefits. 
 
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 50% 
coinsurance for out-of-network covered dental services.  
 
You have been asked to pay 50% coinsurance for an evaluation and x-rays. An evaluation, x-rays, and vitality 
tests fall within the Dental Services benefit category. 
 
Code Allowed Amount 50% Coinsurance 
D0140 $75 $37.50 
D0220 $30 $15 
D0230 $30 $15 
 
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.  
 
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, pulp vitality tests are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay in the full amount for a 
limited oral evaluation (D0140), periapical x-rays (D0220, D0230), and a pulp vitality test (D0460) provided 
on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay an additional $40 for eyeglasses provided on May 6, 2022. 
 
You asked the Plan to pay an additional $40 for the eyeglasses. You say that you overpaid for the vision 
services. The Plan denied your request. The Plan says that the Plan paid the correct $100 allowance. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services with a $100 allowance. 
 
We looked at the file and the Plan's rules. The file shows that the Plan did not pay the maximum eyewear 
allowance of $100. The Plan only paid $60. Therefore, we decided that the Plan has to pay an additional $40 
for eyeglasses provided on May 6, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from October 24, 2020, to 
January 12, 2022.  
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says these services are not covered by your benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided from 
October 24, 2020, to January 12, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs. The 
Plan says that there is no indication that the preferred agents would likely be less effective and/or cause adverse 
effects for the enrollee. 
 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 Euflexxa. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of drug 
Orthovisc, Supartz FX, Durolane, Monovisc, or Synvisc-One before they will approve the requested drug. In 
this case, the enrollee has not tried and failed the required drugs. There is no documentation provided 
indicating that the Plans required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit for an eye exam provided on 
March 31, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that the doctor informed you that you 
have a cataract and you did not get any treatment. You say that your primary care physician always refers you 
to a specialist for diabetic retinopathy and you believe that you should not have to pay for preventive services. 
The Plan denied your request. The Plan says the claim processed correctly. Based on review of additional 
information, it was determined that you did receive an annual eye exam that also addressed a condition of the 
eye. 
 
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 $40 
copayment for Vision Care, Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 You have been asked to pay a $40 copayment for the office visit. The office visit falls within the Vision Care, 
Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye 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 an office visit for an eye exam provided on 
March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
March 23, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this dental work. 
The Plan denied your request. The Plan says covered dental work must be provided within network. 
 
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 covered 
dental services when the services are provided by an in-network provider.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the GTC-Hematology Profile provided on January 10, 
2022. 
 
You asked the Plan to pre-approve the GTC-Hematology Profile. You say that this is a Medicare-covered test. 
The Plan denied your request. The Plan says panels of greater than 51 genes are not considered reasonable and 
necessary per Medicare rules. 
 
The Plan follows Medicare rules. Medicare rules say that molecular diagnostic panels are to be reviewed by the 
MolDX contractor to determine whether they can be covered by Medicare. These tests must also be reasonable 
and necessary for the specific patient.  
 
It was confirmed that the MolDX program has approved this panel of over 51 genes as a coverable test. For this 
reason, a review of medical necessity was performed.   
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 GTC-Hematology Profile. Our 
reviewer says that the documentation does not support the medical necessity of this testing. Our physician 
reviewer found the enrollee has findings of anemia. No marrow testing has yet been done, and the provider 
wishes to rule out myelodysplastic syndrome (MDS). Bone marrow biopsy is needed to diagnose MDS; this 
cannot be done with molecular testing. Without a definitive bone marrow diagnosis of MDS, this testing is not 
considered medically indicated at this time. 
 
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 GTC-Hematology Profile have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the GTC-Hematology Profile provided on January 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our physician reviewer 
found the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the HHA one (1) hour a day, seven (7) days a week. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the information we received does not support the medical need for 4 hours a day, 7 days 
a week of home health aide service. The Plan states the additional hour(s) requested is considered custodial 
care and personal care instead of a medical need. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 services. Our physician reviewer 
found the health plans denial should be upheld. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. As such, home health services, including associated HHA services, 
are not shown to be medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the HHA one (1) hour a day, seven (7) days a week.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network (OON) specialist visit 
provided on March 14, 2022. 
 
You asked the Plan to waive the copayment for the OON specialist visit. You say that you were informed that 
the provider was in-network. 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 $55 
copayment for each out-of-network specialist visit.  
 
The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay a $55 copayment for the OON specialist visit. The OON specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 an out-of-network (OON) specialist visit provided on March 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that an ILR is covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of palpitations 
and possible transient ischemic attack. A recent randomized clinical trial found that continuous monitoring for 
atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) 
was not superior to usual care in reducing stroke or systemic embolism among patients at high risk of stroke 
but without a known prior history of atrial fibrillation. At this time, insertion of an ILR would not be 
considered medically appropriate and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210), bone replacement graft (D7953), and 
intravenous sedation services (D9239, D9243) provided on February 28, 2022. 
 
You asked the Plan to pay for the dental service. You say that simple extractions are listed as a covered service. 
You also say that this service should be covered. The Plan denied your request. The Plan says the services are 
not 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 surgical extraction, bone 
replacement graft, and intravenous sedation services are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pay for the extraction (D7210), bone replacement graft (D7953), and 
intravenous sedation services (D9239, D9243) provided on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous electrical nerve stimulation (PENS) unit. 
 
You asked the Plan to pre-approve a PENS unit. You say that the goal is to help alleviate the enrollee's current 
pain and increase their ability to participate in day-to-day activities with reducing or alleviating the need for use 
of opioid medications. The Plan denied your request. The Plan says the requested device is not a covered 
benefit for the enrollee's condition. 
 
The Plan follows Medicare rules. Medicare rules say that dorsal column or depth brain stimulators are covered 
when certain conditions have been met.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PENS unit. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee being treated for 
spondylosis without myelopathy/radiculopathy of the lumbar region; spondylosis without 
myelopathy/radiculopathy of the lumbosacral region; and polyneuropathy, unspecified. However, specifically, 
in this case, the use of this device is not evident as being of late or last resort. The examination from July 26, 
2022, has a concurrent request for medial branch blocks at L4-5 and L5-S1, bilaterally. This indicates that there 
are continued conservative care measures that can be trialed. Additionally, the documentation does not indicate 
any psychological evaluation/screening has been performed. There is limited published, large-scale, long-term 
peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. 
 
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 PENS unit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous electrical nerve stimulation (PENS) unit.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our physician reviewer 
found you do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat and an air mattress. 
 
You asked the Plan to pre-approve a raised toilet seat and air mattress. You say that you feel that these items 
are medically necessary. The Plan denied your request. The Plan says a raised toilet seat is not a covered 
benefit. Additional clinical information chart notes and information about the enrollee's condition as well as the 
specific type of air mattress being requested is needed from the provider to determine medical necessity. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature. Medicare rules say that the provider, supplier, or beneficiary, 
as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment 
is due and the amount of payment. 
 
 While a raised toilet seat may be appropriate, neither the Plan nor Medicare offers coverage of this item. The 
only information provided for the air mattress was a prescription with no other clinical information. Therefore, 
we decided that the Plan does not have to pre-approve a raised toilet seat and an air mattress.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genetic testing panel 
provided on December 23, 2021. 
 
You asked the Plan to pay for the F1Heme panel. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says this testing is unlikely to impact therapeutic decision making in the clinical 
management of the patient.  
The Plan follows Medicare rules. The rules say that coverage for molecular pathology testing is determined 
based on the guidelines listed in the Medicare rules section of this decision.   
 
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 F1Heme panel. Our reviewer says that 
the requested testing is not medically reasonable and necessary. Our physician reviewer found only a small 
number of the genes included in this extensive panel are supported to guide treatment per the National 
Comprehensive Cancer Network (NCCN) guidelines. 
 
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 F1Heme panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the FoundationOne Heme (F1Heme) genetic testing panel provided on December 23, 2021.