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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a bitewing x-ray 
(D0270) provided on August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the frequency limitations should not apply 
because this was an emergency. The Plan denied your request. The Plan says your benefit for the requested 
items or services 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 a limited oral evaluation was exhausted on date of service January 19, 2022. The record 
also shows your benefit for a bitewing x-ray was exhausted on date of service May 17, 2022. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a bitewing x-ray (D0270) 
provided on August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on September 2, 2022. 
 
You asked the Plan to pay for hearing aids. You say that you have gone to a provider that has a contract with 
your Plan, but the cost is much higher than the provider you went to for this date of service. The Plan denied 
your request. The Plan says there are no provisions in your EOC to obtain hearing aids from non-plan providers 
 
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 the hearing aids are obtained from in-network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids provided on September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92004), scanning computerized 
ophthalmic diagnostic imaging (92134) and a determination of refractive state (92015) provided on August 25, 
2022. 
 
You asked the Plan to pay for a medical eye examination (92004), scanning computerized ophthalmic 
diagnostic imaging (92134) and a determination of refractive state (92015). You say that you are appealing 
with supporting records. 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 medical eye 
examination (92004), scanning computerized ophthalmic diagnostic imaging (92134) and a determination of 
refractive state (92015) provided on August 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission services provided on August 31, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient admission services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the rendered services have 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 inpatient admission services provided on August 
31, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 17, 
2022, to June 20, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
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 $390 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $390 copayment per day for days 1-5 for inpatient hospital care. The total 
allowed amount for the inpatient care is $1,170 ($390 x 3days = $1,170). 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 inpatient 
hospital care provided on June 17, 2022, to June 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
September 18, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you disagree with the 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
emergency 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 emergency room services 
provided on September 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services have 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 an office visit provided on November 17, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing tests (92588, 92567, 92557) provided on August 18, 
2022. 
 
You asked the Plan to pay for hearing tests (92588, 92567, 92557). You say that you do not think the bill is 
correct. You also say you thought you could go anywhere. The Plan denied your request. The Plan says 
according to your EOC, you must receive care from network providers. The Plan also says that the services 
received could have been provided by a participating 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 you use a Plan approved audiologist.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules say you must use a Plan approved audiologist. The 
record shows that a non-participating provider was used. Based on this information, we decided that the Plan's 
rules for coverage of hearing tests (92588, 92567, 92557) have not been met. Therefore, we decided that the 
Plan does not have to pay for hearing tests (92588, 92567, 92557) provided on August 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on October 10, 
2022. 
 
You asked the Plan to waive the copayment for x-ray services. You say that you disagree with the 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 $55 
copayment for outpatient diagnostic tests/x-ray.  
 
You have been asked to pay a $55 copayment for x-ray services. This item/service falls within the outpatient 
diagnostic tests/x-ray 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 x-ray 
services provided on October 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravascular ultrasound, vein dilation, and stenting 
(75820, 75822, 36012, 37252, 37253, 76937, 99152, 75825, 36011, and 99153). 
 
You asked the Plan to pre-approve intravascular ultrasound, vein dilation, and stenting. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that endovenous stents may be placed under certain 
circumstances. 
 
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 intravascular ultrasound, vein dilation, 
and stenting. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not meet coverage criteria and does not support the medical necessity of additional 
treatments. According to the medical record, over the course of a single month, the enrollee underwent venous 
treatments of bilateral great saphenous veins, bilateral small saphenous veins, bilateral posterior accessory 
saphenous vein, and bilateral accessory great saphenous veins. Additionally, during the same year, the enrollee 
underwent sclerotherapy 2. There is documentation that the enrollee experienced symptom relief. On physical 
examination, the enrollee only has edema of the feet. There is no documentation of whole leg edema or 
proximal venous occlusive disease on noninvasive imaging.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intravascular ultrasound, vein dilation, and stenting have not been met. 
Therefore, we decided that the Plan does not have to pre-approve intravascular ultrasound, vein dilation, and 
stenting (75820, 75822, 36012, 37252, 37253, 76937, 99152, 75825, 36011, and 99153).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided on 
September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the fluoride treatment should be covered three 
times a year. 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 topical application of fluoride varnish (D1206) but is limited to two procedures per plan year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested D1206 was exhausted on date of service June 21, 2022. Therefore, we 
decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided on 
September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyedrops provided on June 22, 2022 
 
You asked the Plan to pay for the eyedrops. You say that you want to appeal the denial for the eyedrops you 
purchased for your post-cataract surgery. The Plan denied your request. The Plan says due to the lack of 
necessary reimbursement documentation for the eyedrops. 
 
The Plan must follow Medicare rules. Although the Plan does cover OTC items, documentation is required in 
order to be reimbursed. The record shows the eyedrop receipts were not submitted. Therefore, we decided that 
the Plan does not have to pay for the eyedrops provided on June 22, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391) for tooth #5 provided on 
November 7, 2022. 
 
You asked the Plan to pay for the dental service. You say that you would like the Plan to make an exception 
because you had 3 cavities. 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 requested item or service was exhausted on date of service October 3, 2022. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2391) for tooth #5 
provided on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) and diagnostic eye x-rays 
(92133) provided on May 09, 2022. 
 
You asked the Plan to pay for a medical eye examination (92014) and diagnostic eye x-rays (92133). You say 
that you are appealing because when you go to this provider, they send you the bill. 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 medical eye 
examination (92014) and diagnostic eye x-rays (92133) provided on May 09, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on May 20, 
2022. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that you are appealing to avoid any 
possible financial responsibility. 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 psychiatric diagnostic 
evaluation provided on May 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic breast ultrasound provided 
on October 31, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic breast ultrasound. You say that this service 
should be covered in full. 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 $55 
copayment for each Medicare-covered standard x-ray and ultrasound. 
 
 
 
 You have been asked to pay a $55 copayment for the diagnostic 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 diagnostic breast ultrasound provided on October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral complete 
series of radiographic images (D0210), panoramic radiographic images (D0330), and 2D images (D0350) 
provided on October 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were medically necessary. 
The Plan denied your request. The Plan says your benefit for the comprehensive oral evaluation, intraoral 
complete series of radiographic images, and the panoramic radiographic images has already been exhausted. 
Also, the denial of payment for 2D images is correct, because they are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation, intraoral complete series of radiographic images, 
and the panoramic radiographic images was exhausted on the date of service of September 13, 2019.  The 2D 
images are not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pay for a comprehensive oral evaluation (D0150), intraoral complete series of radiographic images (D0210), 
panoramic radiographic images (D0330), and 2D images (D0350) provided on October 5, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Udenyca, 
 
You asked the Plan to pre-approve Udenyca. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Udenyca. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs would likely be 
less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca,
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a cleaning (D1110), and 
a resin-based composite (D2331) for tooth #11 provided by an out-of-network provider on September 6, 2022, 
and September 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services should be covered because 
they are basic dental services even though the provider is out-of-network. The Plan denied your request. The 
Plan says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), a cleaning (D1110), and a resin-based composite (D2331) for 
tooth #11 provided by an out-of-network provider on September 6, 2022, and September 12, 2022.