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

 
We decided that the Plan does not have to pay more for the eye exam and eyeglasses provided on September 9, 
2022. 
 
You asked the Plan to pay more for the eye exam and eyeglasses. You say that you were told that you should 
never have been charged the additional $27.00, and you would like this refunded to you. The Plan denied your 
request. The Plan says the original determination is upheld. 
 
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 up to $100 per calendar year combined in and out-of-network routine contacts or 
eyeglasses. 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that the Plan paid the full $100 
allowance for the services provided on September 9, 2022, and your eyewear allowance has been exhausted. 
Based on this information, we decided that the Plan's rules for coverage of the eye exam and eyeglasses have 
not been met. Therefore, we decided that the Plan does not have to pay more for the eye exam and eyeglasses 
provided on September 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for elevating leg rests (K0195) provided on August 14, 2022. 
 
You asked the Plan to pay for the elevating leg rests. You say that this item was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must specify whether equipment is rented 
or purchased. For purchased equipment, the itemized bill or claim must also indicate whether equipment is new 
or used. 
 
We looked at the file and Medicare rules. The claim was not billed with a valid modifier to indicate if the item 
was for purchase or rental. Based on this information, we decided that Medicare rules for coverage of the 
elevating leg rests have not been met. Therefore, we decided that the Plan does not have to pay for elevating 
leg rests (K0195) provided on August 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammogram provided on September 29, 2022. 
 
You asked the Plan to pay for a screening mammogram. You say that this service was medically necessary. 
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 screening 
mammogram provided on September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider dropped from the network, so you 
had to select a new provider. You say that the new provider repeated the x-ray, so you should not have to pay 
for it. 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. This benefit includes the 
requested intraoral - complete series of radiographic images (D0210) but is limited to one (D0210/D0330) 
every 36 months. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered panoramic 
radiographic image (D0330) on April 5, 2022. You received intraoral - complete series of radiographic images 
(D0210) on December 14, 2022. Although these are two different services, they fall within the same category 
in your Evidence of Coverage and are subject to the same frequency limitations. Therefore, this benefit has 
been exhausted as of April 5, 2022. Therefore, we decided that the Plan does not have to pay for intraoral - 
complete series of radiographic images (D0210) provided on December 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows facet degenerative joint disease (DJD) 
and canal stenosis. The cause of the enrollee's back pain is unclear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
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 the requested CardioMEMs device is currently considered investigational, has not 
shown to benefit the patients in any large scale randomized clinical trials, and is not recommended by any 
professional and scientific associations/societies to be used in the management of heart failure. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Imaging services provided on September 1, 2022, billed with 
code 78815-26, PS. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis 
code. 
 
The Plan must follow Medicare rules. Medicare rules say the number of PET scans that are allowed are based 
on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis codes 
that may be used. We looked at the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the imaging services provided. have not been met. This claim was billed with diagnosis code C67.9, which is not a valid code for these services. Therefore, we decided that the Plan does not 
have to pay for Imaging services provided on September 1, 2022, billed with code 78815-26, PS.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular reeducation (97112) and the office visit 
(99202) provided on January 13, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit by 
Medicare or the Plan. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the neuromuscular reeducation (97112) and the office visit (99202) 
provided on January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - resin-based composite indirect (D2710). 
 
You asked the Plan to pre-approve crown - resin-based composite indirect. You say that this should be covered. 
The Plan denied your request. The Plan says this is not a covered service. 
 
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 
crown - resin-based composite indirect (D2710).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93010 and 93010-76 billed for date of 
service August 24, 2022. 
 You asked the Plan to pay for procedure codes 93010 and 93010-76. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 93010 is 
bundled into payment for code 92950. 
 
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 93010 
is a column II code to column I code 92950. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 93010 and 93010-76 billed for date of service 
August 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek diabetic test strips. 
 
You asked the Plan to pre-approve Accu-Chek test strips. You say that these items are medically necessary. 
The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered. 
The plan's preferred brand is One-Touch test strips. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Accu-Chek test strips. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek 
diabetic test strips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 1, 
2021, through September 4, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that inpatient care is necessary when the enrollees signs and symptoms and general medical 
condition can only be managed safely in an acute inpatient setting, when the enrollee requires diagnostic 
studies in an inpatient setting, or if it is medically necessary for the enrollee to remain in the acute inpatient 
setting. There must be a reasonable expectation that the enrollees care will need to span two or more 
midnights. Additionally, an enrollee would require an inpatient admission if a surgery/procedure that is to be 
provided is on the Medicare inpatient only list or if the care includes new onset mechanical ventilation. 
In this case, the enrollee was admitted in stable condition and there was not a reasonable expectation that the 
care would need to span two or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from September 1, 2021, through September 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for crown - porcelain/ceramic (D2740) provided on July 
18, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for crown - porcelain/ceramic (D2740) provided 
on July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5274 x 2) and the 
hearing services (V5299) purchased on September 28, 2022. 
 
You asked the Plan to issue reimbursement for these items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these 
items/services are not payable as they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids/services only when obtained from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items/services have not been met. Specifically, the Plans contract states that coverage is 
provided for hearing aids/services only when obtained from the Plans select hearing aid provider. However, 
the hearing aids/services provided in this case were obtained from an out-of-network provider.  Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids (V5274 x 2) and 
the hearing services (V5299) purchased on September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
November 22, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that coverage is provided for 
hearing aids only when purchased through the Plans select hearing aid provider. However, the hearing aids in 
this case were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to 
issue reimbursement for the hearing aids (V5298) purchased on November 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  
September 14, 2021, through September 15, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that inpatient care is necessary when the enrollees signs and symptoms and general medical 
condition can only be managed safely in an acute inpatient setting, when the enrollee requires diagnostic 
studies in an inpatient setting, or if it is medically necessary for the enrollee to remain in the acute inpatient 
setting. There must be a reasonable expectation that the enrollees care will need to span two or more 
midnights. Additionally, an enrollee would require an inpatient admission if a surgery/procedure that is to be 
provided is on the Medicare inpatient only list or if the care includes new onset mechanical ventilation. In 
this case, the enrollee was admitted in stable condition and there was not a reasonable expectation that the care 
would need to span two or more midnights. The acute inpatient hospital care provided was not medically 
necessary.  
 
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 pay for the acute inpatient hospital care provided from September 14, 2021, through September 15, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are unable to care for yourself and that you 
require physical rehabilitation so that you can walk again. The Plan denied your request. The Plan says you no 
longer require skilled services on a daily inpatient basis and the continuation of SNF is not medically 
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 reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of skilled therapy services provided in a skilled 
nursing facility setting. You are not progressing with therapies and continue to be non-ambulatory and 
essentially dependent with performing daily activities. You will continue to require daily assistance with 
mobility and daily activities, but this does not require physical and occupational therapies at the level of acuity 
of the skilled nursing facility 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 skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound (76642) provided on 
December 8, 2022. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you feel this service should 
be covered because it is a result of your yearly mammogram. You also say that something was detected, and 
you needed a follow up to make sure that it was not cancerous. 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 $100 per 
day for a Medicare-covered ultrasound.  
 You have been asked to pay $98.58, which is less than the standard $100 copayment per day for the breast 
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 breast ultrasound (76642) 
provided on December 8, 2022.