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

 
We decided that the Plan does not have to pay for deluxe frames (V2025), lenses (V2100), tinting (V2745), and 
anti-reflective coating (V2750) provided on July 7, 2023. 
 
You asked the Plan to pay for deluxe frames (V2025), lenses (V2100), tinting (V2745), and anti-reflective 
coating (V2750). You say that you had to go to an out-of-network due to emergency. You also say you had to 
find an eyeglasses optical and order glasses so you could receive it as soon as possible to return to work. You 
also say that if you had to go in-network to receive your eyeglasses, it would  be two to six weeks for the 
glasses to arrive. The Plan denied your request. The Plan says the maximum benefit was exceeded for the 
deluxe frames (V2025), and standard lenses (V2100). The Plan also says that tinting (V2745), and anti-
reflective coating (V2750) are not covered by the Plan. 
 
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 the glasses are obtained through an in-network vision provider 
or are basic, standard lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that you must receive services from providers in 
the Plan vision provider network. The record shows you went to an out-of-network vision provider. Tinting 
(V2745) and anti-reflective coating (V2750) are also excluded from the benefit. Based on this information, we 
decided that the Plan's rules for coverage of deluxe frames (V2025), lenses (V2100), tinting (V2745), and anti-
reflective coating (V2750) have not been met. Therefore, we decided that the Plan does not have to pay for 
deluxe frames (V2025), lenses (V2100), tinting (V2745), and anti-reflective coating (V2750) provided on July 
7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the enrollee would benefit from this CGM. The Plan 
denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have a history 
of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 
continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5212). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not covered under the supplemental 
dental policy.  
 
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 item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a lower partial 
denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional miles. You say that you need two additional miles and are 
willing to pay for the extra miles you need to take you home from the hospital. You also say that your doctors 
and hospitals mileage is 52 miles one-way. The Plan denied your request. The Plan says this request will 
exceed the benefit mileage limit. 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 50 miles one-way per trip.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 2 
additional miles for your hospital transport and doctors appointments. 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 routine transportation miles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of impacted tooth - partially bony (D7230 
x4). 
 
You asked the Plan to pre-approve the dental service. You say that there is a bone sticking out that needs to be 
removed in order for your dentures to fit. The Plan denied your request. The Plan says you are only covered for 
the dental services, codes and limits listed in the medical benefits chart. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the removal 
of impacted tooth - partially bony (D7230 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided on May 22, 2023. 
 
You asked the Plan to pay for gingival irrigation. 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 pay for gingival 
irrigation (D4921) provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter (OTC) COVID-19 test kits provided on 
June 26, 2023. 
 
You asked the Plan to pay for over-the-counter (OTC) COVID-19 test kits. You say that you would like a 
prompt review of this appeal and approval of this approved service. The Plan denied your request. The Plan 
says over-the-counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits. Therefore, we decided that the Plan does not have to pay for over-the-counter (OTC) 
COVID-19 test kits provided on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on August 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 September 01, 2021. 
Therefore, we decided that the Plan does not have to pay for core buildup services (D2950) provided on August 
9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
 
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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no magnetic resonance imaging (MRI) showing only Modic changes without facet joint 
degenerative disease or stenosis. The cause of pain is not clear.   
 
  
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the cataract surgery on February 6, 2023, to February 
24, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to reimburse for the cataract surgery. You say that you are requesting reimbursement for 
cataract surgery. The Plan denied your request. The Plan says care the enrollee receives from an out-of-network 
provider will not be covered except in certain situations. 
 
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 reimburse 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 reimburse for these items/services. 
Therefore, we decided that the Plan does not have to reimburse for the cataract surgery on February 6, 2023, to 
February 24, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the office visit (99213) provided on August 14, 
2023, by a provider that has opted out of Medicare. 
 
You asked the Plan to reimburse you for the physician service. You say that you were denied reimbursement 
for an office visit. You say that this is covered in your medical. You also say that you already received a 
reimbursement for your prior visit. The Plan denied your request. The Plan says payment cannot be made for 
services performed by a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the office visit (99213) provided on August 14, 2023, by a provider that has opted out of Medicare.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
May 23, 2023, to June 9, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 $250 
copayment per day, for days one to six, for each inpatient hospital stay. You have been asked to pay a total of $600, which is less than the standard copayment for the inpatient hospital 
stay due to meeting your MOOP amount. 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 the inpatient hospital stay provided from May 
23, 2023, to June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiologic monitoring treatment management 
services provided on March 31, 2023. 
 
You asked the Plan to pay for the remote physiologic monitoring treatment management service. You say that 
the remote monitoring services were not rendered, and you should not be liable for the coinsurance. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% of 
the Medicare-allowed amount for Medicare-covered durable medical equipment for services out-of-network. 
  You have been asked to pay a $23.24 for the remote physiologic monitoring treatment management service 
($46.49 allowed amount x 50% = $23.24). This item/service falls within the durable medical equipment (DME) 
and related 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 pay for the remote physiologic monitoring 
treatment management services provided on March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the enrollees benefit for the requested item 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 was exhausted on date of service July 21, 2023.   
  
 
 
 
 
Specifically, the Plans contract states that a lower partial denture and associated dental items are covered once 
every five calendar years, per arch. The enrollee previously received a lower immediate denture (D5140) on 
July 21, 2023, less than five years prior, which was paid for by the Plan. According to the Plans contract, this 
is an associated dental item to a lower partial denture. Therefore, the enrollee has exhausted the allowable 
benefit for this item at this time. Therefore, we decided that the Plan does not have to pre-approve a lower 
partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K1034) 
provided on June 27, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. You say that you would like the clam to be processed 
towards payment. The Plan denied your request. The Plan says OTC COVID-19 tests, K1034, are not covered 
by Medicare after May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items, including self-
administered COVID-19 tests and the OTC COVID-19 test is an OTC item. Therefore, we decided that the 
Plan does not have to pay for the over-the-counter (OTC) COVID-19 test (K1034) provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy. 
 
You asked the Plan to pre-approve sclerotherapy. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that the enrollee does not have reflux in the 
saphenous vein. 
 
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 sclerotherapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  
 
Our physician reviewer found the documentation does not support the medical necessity of the treatments in 
question. The documentation provided does not demonstrate whether there is satisfactory arterial perfusion to the lower extremities. It is not possible to attribute the enrollee's symptoms or the appropriateness/medical 
necessity of venous treatments without this information.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter (OTC) COVID-19 test kits provided on 
June 26, 2023. 
 You asked the Plan to pay for over-the-counter (OTC) COVID-19 test kits. You say that you would like a 
prompt review of this appeal and approval of this approved service. The Plan denied your request. The Plan 
says over-the-counter (OTC) COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. Although the Plan offers coverage for OTC items, over-the-
counter COVID-19 test kits are excluded from this benefit. Therefore, we decided that the Plan does not have 
to pay for over-the-counter (OTC) COVID-19 test kits provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
November 21, 2022, and billed with codes 87150, 87481, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on November 21, 2022, and billed with codes 87150, 87481, 87798, and 87801.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination and evaluation (92014) provided 
on June 20, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for a medical eye examination and evaluation (92014). You say that the enrollee was 
in a nursing home setting at the time services were rendered. You also say that the enrollee could not choose an 
in-network optometrist as they do not provider services in the enrollee's place of residence. The Plan denied 
your request. The Plan says this provider is not a network provider with the Plan and the services were not 
referred by a network provider or rendered in an in-network facility. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a medical eye examination and evaluation (92014) 
provided on June 20, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no magnetic resonance imaging (MRI) showing only modic changes without facet joint 
degenerative disease or stenosis. 
 
  
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure (64628).