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

 
We decided that the Plan does not have to pay for a specialist office visit provided on September 22, 2022. 
 
You asked the Plan to pay for a specialist office visit. You say that you were referred here. The Plan denied 
your request. The Plan says this office visit has been correctly denied. 
 
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 a specialist office visit provided on September 22, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2335) for tooth #8 and #9, 
provided on September 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that the procedures would be 
covered. The Plan denied your request. The Plan says your benefit for the requested items or services has 
already been exhausted. Also, there was never no predetermination on file for the dental services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service September 16, 2022. 
On August 8, 2022, the Plan paid for 1 resin-based composite. On September 16, 2022, the Plan paid for 3 
resin-based composites. For the year of 2022 the Plan paid for 4 resin-based composites. Therefore, we decided 
that the Plan does not have to pay for resin-based composites (D2335) for tooth #8 and #9, provided on 
September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown lengthening (D4249) and the inhalation of nitrous 
oxide (D9230) provided on September 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial for the dental 
services. The Plan denied your request. The Plan says that the requested services are not covered. 
 
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 crown lengthening (D4249) and 
the inhalation of nitrous oxide (D9230) provided on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on March 2, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the coinsurance. 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 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount for the DME $1,542.60. 
You are being asked to pay $308.52 ($1,542.60 x 20% = $308.52). This item/service falls within the durable 
medical equipment (DME) 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 coinsurance for durable 
medical equipment (DME) provided on March 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
March 11, 2022, to March 15, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with being 
charged as an inpatient. 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 $390 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $390 copayment per day for days 1-4 for an inpatient hospital stay. The total 
amount you are being asked to pay is $1,560 ($390 x 4 days = $1,560). This item/service falls within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient 
hospital stay provided on March 11, 2022, to March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 4, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware of any frequency limits. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. For the year 
of 2022, the Plan paid for periodontal maintenance on January 26, 2022, April 19, 2022, and July 26, 2022. The 
record shows your benefit for the requested item or service was exhausted on date of service July 26, 2022. 
Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on 
October 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on September 06, 
2022. 
 
You asked the Plan to pay for skilled nursing facility services. You say that you are requesting reconsideration. 
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 skilled nursing facility 
services provided on September 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 07, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting a review of medical records and a 
reconsideration of the denied payment. 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 an office visit provided 
on September 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were unable to get an authorization prior to 
services rendered because you were unaware you were out-of-network until after the visit. The Plan denied 
your request. The Plan says an authorization was not obtained prior to services rendered. 
 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 an office visit provided on June 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for durable medical equipment provided from 
August 28, 2022, to September 27, 2022. 
 
You asked the Plan to waive the copayment for durable medical equipment. You say that you believe the Plan 
should be responsible for paying the full amount owed for the durable medical equipment received. 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 20% 
coinsurance for Medicare-covered durable medical equipment.  
 
You have been asked to pay a total coinsurance of $198.53, which is 20% for durable medical equipment 
($992.63 allowed x 20% =$198.53). This item/service falls within the durable medical equipment 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 durable medical equipment provided from 
August 28, 2022, to September 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on August 30, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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 lab testing provided on 
August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay more for eyeglasses provided on October 3, 2022. 
 
You asked the Plan to pay more for eyeglasses. You say that according to your records, you have only 
requested and received $500 of the $750 allotted to your plan. The Plan denied your request. The Plan says that 
you are allowed up to $550 reimbursement per calendar year for out-of-pocket costs. The Plan also says you 
had used $500 of your benefit prior to submitting the reimbursement request for vision hardware in the amount 
of $90. 
 
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. the Plan failed to submit evidence that the enrollee has reached the $550 in 
reimbursement dollars for the pick your perks reimbursement program. Without that proof, we cannot verify 
that the enrollee maxed out their reimbursements. Therefore, we decided that the Plan has to pay more for 
eyeglasses provided on October 3, 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 frames (V2020), progressive lenses (V2781), polycarbonate 
lenses (V2784), antireflective coating (V2750), and vision supply or accessory (V2797) provided on September 
1, 2022. 
 
You asked the Plan to pay for frames (V2020), progressive lenses (V2781), polycarbonate lenses (V2784), 
antireflective coating (V2750), and vision supply or accessory (V2797). You say that this is nothing different 
from last year and you did not owe anything. The Plan denied your request. The Plan says based on your 2022 
EOC, you are responsible for any mount over the $300 retail price. The Plan also said you received a 20% 
discount after deducting the $300 allowance, leaving you a responsibility of $23.96. 
 
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 benefit of up to $300 towards the purchase and fitting of eyeglasses and pair of 
lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that you have a $300 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). The Plan rules also say you 
are responsible for any amount over the $300 retail price. The record shows this benefit was exhausted on 
September 1, 2022. Based on this information, we decided that the Plan's rules for coverage of frames (V2020), 
progressive lenses (V2781), polycarbonate lenses (V2784), antireflective coating (V2750), and vision supply or 
accessory (V2797) have not been met. Therefore, we decided that the Plan does not have to pay for frames 
(V2020), progressive lenses (V2781), polycarbonate lenses (V2784), antireflective coating (V2750), and vision 
supply or accessory (V2797) provided on September 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on November 
9, 2022. 
 
You asked the Plan to waive the copayment for specialist services. You say that you cannot afford this 
copayment. 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 $45 
copayment for physician/practitioner services/in-network/specialist office visit.  
 
You have been asked to pay $39.76 which is less than your copayment amount of $45 for specialist services. 
This item/service falls within the physician/practitioner services/in-network/specialist office visit 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 specialist services provided on November 9, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in your 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelegy Ellipta. 
 
You asked the Plan to pre-approve Trelegy Ellipta. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trelegy Ellipta.  
 
Benefits for Trelegy Ellipta 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), panoramic radiographic image (D0330), and periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) provided on August 3, 2022, and September 9, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation - new or established patient (D0150) was exhausted 
on date of service March 16, 2021. The record shows your benefit for the panoramic radiographic image 
(D0330), and periodontal scaling and root planing - four or more teeth per quadrant (D4341) was exhausted on 
date of service March 19, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive 
oral evaluation - new or established patient (D0150), panoramic radiographic image (D0330), and periodontal 
scaling and root planing - four or more teeth per quadrant (D4341) provided on August 3, 2022, and September 
9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for progressive lenses (S0581), deluxe frames (V2025), sphere, 
bifocal (V2200), photochromatic tint (V2744), anti-reflective coating (V2750), and lenses (V2782) provided on 
September 12, 2022. 
 
You asked the Plan to pay for progressive lenses (S0581), deluxe frames (V2025), sphere, bifocal (V2200), 
photochromatic tint (V2744), anti-reflective coating (V2750), and lenses (V2782). You say that the provider is 
supposed to accept the contracted amount and her glasses should have been covered in full. The Plan denied 
your request. The Plan says upgrades are not covered for glasses/lenses after cataract surgery. The Plan also 
says you must pay for upgrades yourself if you choose. 
 
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 when you do not purchase lens upgrades. 
 
We looked at the file and the Plan's rules. The Plan rules say that they do not cover lens upgrades, including but 
not limited to deluxe frames, transition, progressive, scratch resistant, polish or tinted lenses, or insurance. 
Based on this information, we decided that the Plan's rules for coverage of progressive lenses (S0581), deluxe 
frames (V2025), sphere, bifocal (V2200), photochromatic tint (V2744), anti-reflective coating (V2750), and 
lenses (V2782) have not been met. Therefore, we decided that the Plan does not have to pay for progressive 
lenses (S0581), deluxe frames (V2025), sphere, bifocal (V2200), photochromatic tint (V2744), anti-reflective 
coating (V2750), and lenses (V2782) provided on September 12, 2022.