Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on June 13, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
durable medical equipment provided on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound care services provided from 
January 14, 2022, to August 19, 2022. 
 
You asked the Plan to waive the copayments for the wound care services. You say that you cannot afford the 
high copayments. 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 $295 
copayment for outpatient hospital facility visits.  
 
You have been asked to pay a $295 copayment for each of the 8 wound care services, for a total of $2,360. This 
item/service falls within the outpatient hospital facility 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 copayments for wound care services provided from January 14, 2022, to August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 23, 2022. 
 
You asked the Plan to pay for the office visit. You say that the enrollee changed plans and you were unaware 
that a referral was now required. 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 the office visit provided 
on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020) and progressive lenses (V2781) provided on 
August 3, 2022. 
 You asked the Plan to pay for frames (V2020) and progressive lenses (V2781). You say that your coverage 
includes one pair of prescription eyeglasses per year. You also say that the eyeglasses provider said that the 
plans often cover their eyeglasses, but you need to submit the claim form yourself. The Plan denied your 
request. The Plan says the out-of-network benefit for frames and lenses has a member liability of any amount 
over the $200 retail price. The Plan also says that the claim will not pay out the $200 it deducts it from the total 
retail price/submitted charge to come up with the member's remaining responsibility. 
 
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 cover up to $200 (combined in and out-of-network) toward the 
purchase and fitting of eyeglasses and pair of lenses (1 per calendar year). 
 
We looked at the file and the Plan's rules. The Plan rules say that you have a $200 (combined in and out-of-
network) benefit toward the purchase and fitting of eyeglasses and pair of lenses (1 per calendar year). The 
Plan rules also say that you pay any amount over the $200 retail price. The record shows that the benefit was 
exhausted with this visit. Based on this information, we decided that the Plan's rules for coverage of frames 
(V2020) and progressive lenses (V2781) have not been met. Therefore, we decided that the Plan does not have 
to pay for frames (V2020) and progressive lenses (V2781) provided on August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pacemaker check provided on June 08, 
2022. 
 
You asked the Plan to waive the copayment for pacemaker check. You say that you disagree with the 
copaymet. 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 Prosthetic devices and related supplies/pacemaker checks. 
 
You have been asked to pay a $45 copayment for pacemaker check. This item/service falls within the 
Prosthetic devices and related supplies/pacemaker checks 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 pacemaker check provided on June 08, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for procedure code 88360. 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 88360 is bundled into 
payment for code 88321. 
 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 88360 
is a column II code to column I code 88321. 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 code 88360 billed for date of service July 14, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the coronavirus vaccine administration (0064A) provided on November 
15, 2021. 
 
You asked the Plan to pay for the vaccine. You say that this should be covered under the enrollees plan. The 
Plan denied your request. The Plan says that this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, there was no documentation provided to 
show that this service was paid. Based on this information, we decided that Medicare rules for coverage of the 
vaccine have been met. Therefore, we decided that the Plan has to pay for the coronavirus vaccine 
administration (0064A) provided on November 15, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty wheelchair (K0006). 
 
You asked the Plan to pre-approve a wheelchair. You say that the enrollee will need continued use of a 
wheelchair to prevent serious injury and is a high fall risk. The Plan denied your request. The Plan says the 
enrollee is below the minimum weight required for the requested wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The enrollee's current weight is 206 pounds. The rules say that the 
enrollee must weigh more than 250 pounds to qualify for the requested wheelchair. Based on this information, 
we decided that Medicare rules for coverage of a wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a heavy-duty wheelchair (K0006).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
and an intraoral - periapical each additional radiographic image (D0230) provided on August 23, 2022. 
 
You asked the Plan to pay for an intraoral - periapical first radiographic image (D0220), and an intraoral - 
periapical each additional radiographic image (D0230). You say that the Plan claims these codes are not 
covered when in fact, the EOC clearly states they are. The Plan denied your request. The Plan says this service 
is not covered under any normal circumstances. 
 
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 an intraoral - periapical first 
radiographic image (D0220), and an intraoral - periapical each additional radiographic image (D0230) provided 
on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper denture (D5130). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs to have upper and lower 
dentures made. 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 the enrollees benefit for the requested item or service was exhausted on the date of service of February 
11, 2021. Therefore, we decided that the Plan does not have to pre-approve an upper denture (D5130).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 requested items was exhausted on date of service October 10, 2022. Specifically, the 
Plan contract provides coverage for one upper and/or one lower partial denture every 5 years. You previously 
received these items on October 10, 2022, which were paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for these items. Therefore, we decided that the Plan does not have to pre-approve an upper 
partial denture (D5213) and a lower partial denture (D5214).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is a long term care resident with this 
facility. The Plan denied your request. The Plan says network providers are available to provide necessary care. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) care to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nitrous oxide inhalation anxiolysis, analgesia (D9230). 
 
You asked the Plan to pre-approve dental services. You say that you would like the requested services to be 
approved. The Plan denied your request. The Plan says this service is not covered under your 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. Nitrous oxide inhalation 
anxiolysis, analgesia (D9230) are not covered under the Plans dental benefits. 
 
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 
nitrous oxide inhalation anxiolysis, analgesia (D9230).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image 
(D0230) and topical application of fluoride varnish (D1206) provided on October 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered because this 
was only your second standard cleaning visit. The Plan denied your request. The Plan says your benefit for the 
intraoral x-ray has already been exhausted, and the fluoride varnish is not a covered benefit. 
 
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 intraoral x-ray was exhausted on the same date of service, October 4, 2022. Though 
the Plan offers dental benefits in excess of Medicare coverage, the fluoride varnish is not among those covered 
services. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional 
radiographic image (D0230) and topical application of fluoride varnish (D1206) provided on October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for frames (V2020), anti-reflective coating (V2750), 
polarization (V2762), lenses (V2783), and progressive lenses (V2781) provided on July 19, 2022.  
You asked the Plan to pay more for frames (V2020), anti-reflective coating (V2750), polarization (V2762), 
lenses (V2783), and progressive lenses (V2781). You say that $200 does not come close to paying for glasses. 
The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded limits set 
in the subscriber agreement. 
 
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 up to $200 towards eyeglasses. 
 
We looked at the file and the Plan's rules. The Plan rules say that eyeglasses are covered up to a maximum 
annual amount of $200. You are responsible for any amount over $200. Based on this information, we decided 
that the Plan's rules for coverage of frames (V2020), anti-reflective coating (V2750), polarization (V2762), 
lenses (V2783), and progressive lenses (V2781) have not been met. Therefore, we decided that the Plan does 
not have to pay more for frames (V2020), anti-reflective coating (V2750), polarization (V2762), lenses 
(V2783), and progressive lenses (V2781) provided on July 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care, per day (99223) and the advanced 
care planning (99497) provided on August 9, 2022. 
 
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 services at issue are not payable as 
original Medicare is responsible for coverage. 
 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 August 3, 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 the initial hospital 
care, per day (99223) and the advanced care planning (99497) provided on August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry office visit provided on July 19, 2022. 
 
You asked the Plan to pay for podiatry office visit. You say that you were unaware an authorization was 
required when you started looking for a new podiatrist. 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 podiatry office visit 
provided on July 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for cystoscopic biopsy and fulguration 
provided on September 13, 2022. 
 
You asked the Plan to waive the coinsurance for cystoscopic biopsy and fulguration. You say that you are 
disputing the share cost. 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 Outpatient hospital services. 
 
You have been asked to pay 20% coinsurance for cystoscopic biopsy and fulguration. This item/service falls 
within the Outpatient hospital 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 coinsurance for 
cystoscopic biopsy and fulguration provided on September 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips. 
 
You asked the Plan to pre-approve the additional non-emergency transportation trips. The Plan denied your 
request. The Plan says you have exhausted all trips for the benefit year. This request is not covered by your 
Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation trips.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve additional acupuncture services. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you have exhausted the allowable benefit for the 
requested services. 
 
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. Specifically, we requested the medical records that pertain to this case from the 
Plan; however, these records have not been submitted. Additionally, we requested documentation from the Plan 
that demonstrated that you have exhausted the allowable supplemental acupuncture benefit. However, the Plan 
has not provided the requested information. The Plan has not substantiated their denial; therefore, we must find 
in your favor. Therefore, we decided that the Plan has to pre-approve additional acupuncture services.  
 
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.