Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 25, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that the provider is requesting to reconsider the claim for 
payment and seeking for review. The Plan denied your request. The Plan says the services are not authorized 
because the requested provider is a non-provider who does not work with the enrollee's health Plan. 
 
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 April 25, 2023, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrodes (A4556) provided on March 28, 2023. 
 
You asked the Plan to pay for the electrodes. You say that the item should be covered. The Plan denied your 
request. The Plan says this code is not valid for claim submission. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the electrodes have not been met. Therefore, we decided that the Plan does not have to pay for the 
electrodes (A4556) provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 27, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that it is medically necessary. The Plan denied your 
request. The Plan says this provider is not a network provider. 
 
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 April 27, 2023, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use 
(D9630) provided on February 25, 2023. 
 
You asked the Plan to pay for drugs or medicaments dispensed in the office for home use (D9630). You say 
that the treatment done was billed incorrectly by the dental office. The Plan denied your request. The Plan says 
this service is not a covered expense under the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 drugs or 
medicaments dispensed in the office for home use (D9630) provided on February 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental cleaning (D4910) provided on July 10, 2023.

You asked the Plan to pay for the dental services. You say that you need the cleaning due to your gum condition. 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 Plan's 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 dates of service January 3, 2023, and April 6, 2023. Therefore, we decided that the Plan does not have to pay for a dental cleaning (D4910) provided on July 10, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ER visit provided from April 19, 2023, 
to April 21, 2023. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the cost share 
applied. 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 $125 
copayment per visit for emergency care.  
 
You have been asked to pay a $125 copayment for an ER visit. 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 an ER visit provided from April 
19, 2023, to April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical first x-ray (D0220), core buildup (D2950) and 
intra-orifice barrier (D3911) provided on March 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says these services are either not a covered benefit under your dental plan or the benefit 
has 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 D0220 was exhausted on date of service January 17, 2023. Additionally, D2950 and 
D3911 are not covered under any circumstance. Therefore, we decided that the Plan does not have to pay for 
the periapical first x-ray (D0220), core buildup (D2950) and intra-orifice barrier (D3911) provided on March 
25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 14, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration on the denied 
claim. The Plan denied your request. The Plan says the claim was processed correctly. 
 
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 March 14, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 28, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the claim for 
payment. The Plan denied your request. The Plan says services from non-participating providers are not 
covered under the enrollee's Plan unless they are authorized by Aetna before the services are provided. 
 
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 September 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 24, 2023, to May 8, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that your staff was not aware of prior authorization 
requirements at time of visit. The Plan denied your request. The Plan says the service obtained by the enrollee 
was rendered by a provider who is not under contract. 
 
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 April 24, 2023, to May 
8, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating, the ultraviolet lens, the bifocal 
lens, the routine eye examination, the frames, and the not medically necessary service provided on March 31, 
2023. 
 
You asked the Plan to pay for the anti-reflective coating, the ultraviolet lens, the bifocal lens, the routine eye 
examination, the frames, and the not medically necessary service . You say that you resubmitted the claim form 
with the corrected procedure code. You say you do not recall payment for glasses within the last two years. The 
Plan denied your request. The Plan says the benefit has been exhausted for the eyewear and the routine eye 
examination and the not medically necessary service are not covered benefits. 
 
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 $100 benefit every two years towards eyewear. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $100 towards eyewear on May 27, 2021, 
which exhausted the benefit. The record shows the routine eye examination, and the not medically necessary 
service are not covered benefits. Based on this information, we decided that the Plan's rules for coverage of the 
anti-reflective coating, the ultraviolet lens, the bifocal lens, the routine eye examination, the frames, and the not 
medically necessary service  have not been met. Therefore, we decided that the Plan does not have to pay for 
the anti-reflective coating, the ultraviolet lens, the bifocal lens, the routine eye examination, the frames, and the 
not medically necessary service provided on March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the drug injection and each vision care 
office visit provided from April 28, 2023, to May 26. 2023. 
 
You asked the Plan to waive the cost share for the drug injection and each vision care office visit. You say that 
you want to appeal the cost share for these services. 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 Medicare Part B drugs. Your contract with the Plan also clearly says that you must pay a $15 copayment for each vision care office visit. 
 
You have been asked to pay $14.27, which is 20% coinsurance of the allowed amount for the drug injection 
($71.35 allowed amount x 20% coinsurance = $14.27). This item/service falls within the Medicare Part B drugs 
benefit category. You have also been asked to pay a $15 copayment for each vision care office visit. This 
item/service falls within the vision 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 cost share 
for the drug injection and each vision care office visit provided from April 28, 2023, to May 26. 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0220), the core buildup 
(D2950), and the crown (D2740) for tooth #4 and #5 provided on April 20, 2023. 
  
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 annual dental maximum benefit for the year has already been 
exhausted. Also, the core buildup is 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 Plan's 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 Plan paid $115 for dental services on February 22, 2023. On March 8, 2023, the Plan paid $1,000 for 
dental services. On April 6, 2023, the Plan paid $28 for dental services. On April 20, 2023, the Plan paid $857 
for dental services. For the year of 2023 the Plan paid $2,000 ($115 paid + $1,000 paid + $28 paid + $857 paid) 
for dental services; therefore, the enrollee's benefit for the year of 2023 was exhausted on the date of service of 
April 20, 2023. The core buildup is not covered under the Plan's dental benefit. Therefore, we decided that the 
Plan does not have to pay for the intraoral radiographic image (D0220), the core buildup (D2950), and the 
crown (D2740) for tooth #4 and #5 provided on April 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for an intraoral x-ray, filling, crown, and core buildup services (D2392, D2740, D2950, D0220) provided on May 15, 2023.

You asked the Plan to pay more for the dental services. You say that the services should be covered as you disagree with the charges. 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 Plan's 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 May 15, 2023. Therefore, we decided that the Plan does not have to pay more for an intraoral x-ray, filling, crown, and core buildup services (D2392, D2740, D2950, D0220) provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation and services provided on May 09, 
2023. 
 
You asked the Plan to pay for a home visit evaluation and services. You say that you are requesting 
reconsideration of the denied claim. 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 home visit evaluation 
and services provided on May 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 27, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are disputing the denied claim. The Plan denied 
your request. The Plan says the services are not authorized because the requested provider is a non-network 
provider who does not work with the enrollee's health Plan. 
 
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 March 27, 2023, by an 
out-of-network (OON) provider.
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 an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the enrollee had an 
epidural steroid injection on May 23, 2023, which provided 30% pain relief in their lower back and left leg. 
The LCD criteria requires 50 % pain relief for three months which was not achieved. Therefore, the request is 
not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs more intensive care 
than a skilled nursing can provide for current medical conditions. The Plan denied your request. The Plan says 
the enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve the genicular radiofrequency ablation. You say that that the procedure 
would stop the pain you are having from your osteoarthritis. The Plan denied your request. The Plan says the 
genicular radiofrequency ablation 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 genicular radiofrequency ablation. 
Our reviewer says that the genicular radiofrequency ablation is not medically necessary. Our physician 
reviewer found that the genicular radiofrequency ablation is the subject of ongoing clinical trials and is 
considered an experimental and investigational procedure. 
 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 genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the genicular radiofrequency ablation.