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

 
We decided that the Plan does not have to pay for the disposable contact lenses provided on November 9, 2022. 
 
You asked the Plan to pay for the disposable contact lenses. You say that you had no idea that the provider was 
out-of-network. You say you have already paid $400 out-of-pocket and should be reimbursed. The Plan denied 
your request. The Plan says the benefit has been exhausted.  
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 has a $200 allowance to pay towards covered contact lenses. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $200 towards the contact lenses on 
November 9, 2022, which exhausted the benefit. Based on this information, we decided that the Plan's rules for 
coverage of the disposable contact lenses have not been met. Therefore, we decided that the Plan does not have 
to pay for the disposable contact lenses provided on November 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the euflexxa (J7323). 
 
You asked the Plan to pre-approve the euflexxa. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says step therapy requirements have not been met. 
 
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 the euflexxa. Our reviewer says that 
step therapy requirements have not been met. Our physician reviewer found the enrollee has not tried and failed 
the required drug and the documentation does not support that required drugs would likely be less effective, 
and/or would likely have adverse effects for the enrollee in this case. 
 
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 euflexxa have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the euflexxa (J7323).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the abdominal ultrasound provided on August 12, 
2022. 
 
You asked the Plan to waive the coinsurance for the ultrasound. You say that you should not have any 
coinsurance for this procedure. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms 
how much you should expect to pay for each Medicare-covered diagnostic radiology service, including 
ultrasounds.  
 
We looked at your contract with the Plan. The Plan contract does not clearly say how much enrollees must pay 
for each Medicare-covered diagnostic radiology service, including ultrasounds. This means that the Plan did 
not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to 
waive the coinsurance for the abdominal ultrasound provided on August 12, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on November 8, 
2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you had confirmed that this 
procedure was a covered service before it was provided. 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 $300 
copayment for each Medicare-covered CT scan.  
 
You have been asked to pay a $300 copayment for the CT scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic 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 CT scan provided on November 8, 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 care you need can only be provided 
at a LTACH. The Plan denied your request. The Plan says an 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 that was provided indicating medical necessity for 
admission to a LTACH. You do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the CT scan provided on January 6, 2022, 
and the physical therapy services provided on January 7, 2022. 
 
You asked the Plan to waive the copayments for the CT scan and physical therapy. You say that you would like 
to appeal these charges. 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 $50 
copayment for each Medicare-covered diagnostic radiology service, including CT scans. Your contract with the 
plan also says that you must pay a $15 copayment for each physical therapy visit. 
 
You have been asked to pay a $50 copayment for the CT scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services benefit category. You have also been asked to pay a $15 copayment for the physical therapy visit. This item/service falls within the outpatient rehabilitation services benefit 
category. You have been asked to pay a total of $65 ($50 copayment + $15 copayment = $65). 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 copayments for the CT scan provided on January 6, 2022, and the physical therapy 
services provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan provided on January 31, 2022. 
 
You asked the Plan to pay for duplex scan. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
   
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 24, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for duplex scan 
provided on January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance 
(E0673) and pneumatic compression device (E0675) provided on July 19, 2022. 
 
You asked the Plan to pay for the segmental gradient pressure pneumatic appliance and pneumatic compression 
device. You say that you believe there is a misunderstanding on the use of the place of service codes. The Plan 
denied your request. The Plan says the pneumatic compression device (E0675) is not a covered service. The 
Plan also says that the place of service code on the claim line does not meet definition of DME when used 
outside the home for procedure code E0673. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the segmental gradient pressure pneumatic appliance (E0673) and pneumatic compression 
device (E0675) provided on July 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injectafer (J1439). 
 
You asked the Plan to pre-approve injectafer. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not met the step therapy requirements. 
 
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 injectafer. Our reviewer says that the 
item is not medically necessary. Our physician reviewer found there is no documentation of trial and failure of 
the Plan's step therapy requirements, and the documentation does not support that the required drug would 
likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve injectafer (J1439).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on 
December 14, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you did not know there would be 
an extra charge for this service. 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 $50 
copayment for each in-network Medicare-covered ultrasound.  
 
You have been asked to pay a $50 copayment for the ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic 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 breast ultrasound provided on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adult 
dentition (D8090). 
 
You asked the Plan to pre-approve the comprehensive orthodontic treatment of the adult dentition (D8090). 
You say that the service is medically necessary. You also say that this is due to previous bridge work which has 
become loosened due to the misalignment in your upper teeth. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive orthodontic treatment of the adult dentition (D8090).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies not used with external infusion pump 
(A4223) provided from July 20, 2022, to July 22, 2022. 
 
  You asked the Plan to pay for the infusion supplies. You say that your department requires reimbursement for 
the underpaid charges that is indicated on the claims that include the necessary supplies and service charges 
applicable to the medication being administered to the enrollee. The Plan denied your request. The Plan says 
code A4223 has a medical unlikely edit (MUE) value of 0, and is not eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A4223 is not supported because the MUE is 0, and no units of this code are appropriate 
to report. Based on this information, we decided that Medicare rules for coverage of the infusion supplies have 
not been met. Therefore, we decided that the Plan does not have to pay for the infusion supplies not used with 
external infusion pump (A4223) provided from July 20, 2022, to July 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the upper and 
lower spine provided on April 22, 2022. 
 
You asked the Plan to pay for the imaging services. You say that you were in pain and the MRI was necessary 
to find out what was going on. The Plan denied your request. The Plan says the requested payment for the 
services is not covered under Medicare. 
 
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 ordering physician was a chiropractor and the services provided were not manual 
manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the magnetic resonance 
imaging (MRI) of the upper and lower spine provided on April 22, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown (D2750) for tooth #4 provided on October 13, 2022. 
 
You asked the Plan to pay for the dental service. You say that there was little tooth left and the procedure was 
medically necessary. The Plan denied your request. The Plan says that the x-rays show that 50% of the tooth 
was lost. 
 
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. There was no medical documentation to support the Plan's denial which is 
necessary for us to review the denial. Therefore, we decided that the Plan has to pay for a crown (D2750) for 
tooth #4 provided on October 13, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial observation care services provided on October 16, 2022. 
 
You asked the Plan to pay for the billed services. You say that supporting documentation was provided. The 
Plan denied your request. The Plan says that payment is not appropriate for the procedure code billed. 
 
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. 
 
We looked at the file and the rules. The Plan has not clearly asserted their reason for the denial of services. The 
Plan has not cited a specific Medicare rule that pertains to the observation code billed; instead, referring to a 
whole section in a manual that covers a wide array of topics. The Plan has not made reasonable and diligent 
efforts to gather and forward to us information regarding their decision to deny your request.  Therefore, we 
decided that the Plan has to pay for the initial observation care services provided on October 16, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care for the enrollee is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not need an intensive program and their needs can be 
bet at a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for thoracolumbar spine surgery. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to pay for eyewear frames examination provided on November 23, 2022.. You say that you 
are not sure you received this bill. The Plan says that the Plan has paid the $100 lens and frames benefit, so 
additional payment is not covered. 
 
We decided that the Plan has to pay an additional $40 for frames.  
 
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 frames and lenses once per calendar year up to a $100 benefit. 
 
We looked at the file and the Plan's rules. The record shows that the Plan only paid $60 toward your combined 
frame/lenses benefit. The Plan also paid $40 for a routine eye exam; however, this amount would apply toward 
the routine eye exam allowance and not the frames/lenses benefit. Therefore, the Plan has not shown that they 
fulfilled your $100 frames/lenses benefit for the calendar year of 2022. The Plan must pay an additional $40 
toward the frames/lenses benefit in order to fulfill this benefit. Therefore, we decided that the Plan has to pay 
an additional $40 for frames.  
 
We also decided that the Plan does not have to fully pay for frames. 
 
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 frames and lenses once per calendar year up to a $100 benefit. 
 
We looked at the file and the Plan's rules. After the Plan complies with our decision, your $100 frames/lenses 
benefit for 2022 will be exhausted. You are responsible for payment of any amount above this $100 retail price. 
Therefore, we decided that the Plan does not have to fully pay for frames. 
 
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.