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

 
We decided that the Plan does not have to pay for digital hearing aids (V5261) provided on March 9, 2023. 
 
You asked the Plan to pay for digital hearing aids (V5261). You say that this provider has a much lower 
provide than with the Plan vendor. The Plan denied your request. The Plan says services were not provided by 
preferred network 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 obtained through a Plan hearing vendor.  
 
 
  We looked at this the file, and the Plan's rules. The Plan rules also says that members are required to contact the 
Plans hearing vendor to access the routine hearing examination and supplemental hearing aid benefits. The 
record shows that you did not contact the Plan to access your routine hearing examination and supplemental 
hearing aid benefit. The record also shows you went to an out-of-network provider. Based on this information, 
we decided that the Plan's rules for coverage of digital hearing aids (V5261) have not been met. Therefore, we 
decided that the Plan does not have to pay for digital hearing aids (V5261) provided on March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite (D2394) provided on September 
19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this service 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 resin-based composite (D2394) provided on 
September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on October 27, 2022, to December 
21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not agree with the denial of payment for 
services you received. 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 dental services provided on October 27, 2022, to December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established 
patient (D0180) provided on March 23, 2023. 
 
You asked the Plan to pay for dental services. You say that you had to see a new provider, so you feel the 
service should be covered. 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. Comprehensive periodontal 
evaluation - new or established patient (D0180) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0180 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for comprehensive 
periodontal evaluation - new or established patient (D0180) provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection.  
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection 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 the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the LCD criteria requires at 
least 50% pain relief for three months. However, three months has not yet passed and therefore, the criteria are 
not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 rendered on June 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code is not supported. 
 
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, the CPT Code Manual definition of code 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that this evaluation and management 
service was reported with modifier 25 - significant, separately identifiable evaluation and management service 
by the same physician or other qualified health care professional on the same day of procedure or other service. 
The records do not include any documentation to confirm a separately identifiable evaluation and management 
service. Therefore, the code cannot be verified. CPT 99204 was related to the procedure that was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99204 rendered on June 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93016 and 93018 rendered on January 4, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the billed codes are not supported. 
 
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, the CPT Code Manual definition of the denied codes is: 
 
93016 - Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous 
electrocardiographic monitoring, and/or pharmacological stress; supervision only, without interpretation and 
report 
 93018 - Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous 
electrocardiographic monitoring, and/or pharmacological stress; interpretation and report only 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
include any documentation of a cardiovascular stress test. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 93016 and 93018 rendered on January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a problem focused limited oral evaluation (D0140), or pay 
more for the extraction of an erupted tooth (D7210) provided on April 18, 2023.  
 
You asked the Plan to pay for the dental services. You say that you called the providers office to see if they 
accept your insurance plan. You also say the provider told you they did accept your insurance. 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 a problem focused limited oral evaluation (D0140) was exhausted on March 30, 2023. You have also 
been asked to pay the difference between the out-of-network providers charges and the Plans payment for the 
extraction of an erupted tooth (D7210). 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 a problem focused 
limited oral evaluation (D0140), and to pay more for the extraction of an erupted tooth (D7210) provided on 
April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2392 and D2391) provided on 
March 8, 2023. 
 
You asked the Plan to pay for D2392 and D2391. You say that you were misled to believe that these services 
were covered. The Plan denied your request. The Plan says the rendered dental services are not covered 
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. 
 
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 resin-
based composites (D2392 and D2391) provided on March 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you need this CGM to monitor your glucose monitor. 
The Plan denied your request. The Plan says this CGM is not medically necessary. 
 
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 use insulin. 
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 continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart Implantable Pulse Generator 
(0408T). 
 
You asked the Plan to pre-approve the Optimizer Smart Implantable Pulse Generator. You say that this is 
medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the 
Optimizer Smart Implantable Pulse Generator device has not been demonstrated in the peer-reviewed literature. 
 
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 the Optimizer Smart Implantable Pulse 
Generator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found cardiac contractility modulation (CCM) systems remain 
the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Optimizer Smart Implantable Pulse Generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Optimizer Smart Implantable Pulse Generator 
(0408T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the dispensing fee (V5160), sales tax 
(S9999), ear impressions (V5275), and the hearing aids (V5298) purchased on February 10, 2023. 
 
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 the items at issue are not payable 
as they were rendered by 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 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 have not been met. Specifically, the Plans contract states that coverage is provided for 
hearing aids only when purchased from 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 dispensing fee (V5160), sales tax (S9999), ear impressions (V5275), and the 
hearing aids (V5298) purchased on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 30, 2023. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for the services 
provided. 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 office visit provided on 
March 30, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosentyx (J3590). 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cosentyx (J3590).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on April 18, 
2023, by an OON provider.  
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you tried to find an in-
network provider, but none were taking new patients. The Plan denied your request. The Plan says this provider 
is not eligible to provide services under this policy. 
 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 Plan contract says that a counselor is not eligible to provide 
outpatient mental health services. 
 
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 the psychiatric diagnostic evaluation provided on 
April 18, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve acupuncture treatments (97810, 97811). 
 
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 do not meet criteria for coverage of 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, the Plan has stated that you do not meet criteria for coverage of 
Medicare-covered acupuncture treatments. However, your request in this case is for acupuncture treatments for 
foot drop. The Plans contract states that 30 visits of combined treatment for routine acupuncture and 
chiropractic services are covered per year. The Plan has not substantiated their denial; therefore, we must find 
in your favor. Therefore, we decided that the Plan has to pre-approve acupuncture treatments (97810, 97811).  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 13, 2022, to 
December 12, 2022. 
 
You asked the Plan to pay for home health services. You say that you do not agree with the denial of payment 
for home health services. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 14, 2022. The NOA was not received by the Plan until December 
21, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from November 13, 2022, to December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional periapical image (D0230) provided on April 
17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this additional x-ray. 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 April 17, 2023. 
Therefore, we decided that the Plan does not have to pay for an additional periapical image (D0230) provided 
on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5254) purchased on 
March 4, 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 the items at issue 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 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 have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from 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 (V5254) purchased on March 4, 2022.