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

 
We decided that the Plan does not have to waive the copayment for an out-of-network diagnostic eye exam 
provided on November 14, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network diagnostic eye exam. You say that this 
should be covered at the $10 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 $75 
copayment for out-of-network vision care.  
 
You have a $75 copayment + $36 non-covered eye testing, resulting in a total copayment of $111. 
 You have been asked to pay a $111 total cost for an out-of-network diagnostic eye exam. This item/service 
falls within the out-of-network 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 copayment 
for an out-of-network diagnostic eye exam provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on February 23, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this 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 dental services provided on February 23, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 2, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your heart 
started to beat fast and you thought you had low potassium. You also say that by time the paramedics arrived 
your heart stopped racing and due to the bad weather, you declined the transportation to the hospital. The Plan 
denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 2, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for single vision lens (V2100), polycarbonate lens (V2784) and 
frames (V2025) provided on March 16, 2023. 
 
You asked the Plan to pay for single vision lens (V2100), polycarbonate lens (V2784) and frames (V2025). 
You say that you were told by the Plan that this provider is in-network, and you would not have to pay. The 
Plan denied your request. The Plan says per the Plans EOC, you have a $200 allowance for non-Medicare 
covered eyewear every year. The Plan also says that you are responsible for all costs over and above the 
allowance amount. 
 
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 a $200 allowance for non-Medicare covered eyewear every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover a $200 allowance for non-
Medicare covered eyewear every year. The Plan rules also say you are responsible for all costs over and above 
the allowance amount. Based on this information, we decided that the Plan's rules for coverage of single vision 
lens (V2100), polycarbonate lens (V2784) and frames (V2025) have not been met. Therefore, we decided that 
the Plan does not have to pay for single vision lens (V2100), polycarbonate lens (V2784) and frames (V2025) 
provided on March 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on November 15, 2022. You asked the Plan to pay for the ambulance service transport, and ground mileage. You say that you received 
a letter from hospice stating the enrollee was not enrolled on this date. The Plan denied your request. The Plan 
says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 19, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport, and ground mileage provided on November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a thoracentesis procedure provided on 
February 23, 2023. 
 
You asked the Plan to reduce the copayment for a thoracentesis procedure. You say that you only paid $110 for 
this procedure in the past. 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 $270 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. 
 
You have been asked to pay a $270 copayment for a thoracentesis procedure. This item/service falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities 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 reduce the copayment for a thoracentesis procedure provided on February 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after August 13, 
2023. 
 You asked the Plan to pre-approve SNF care after August 13, 2023. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care after August 13, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after August 13, 2023, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after August 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (D6014). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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. Therefore, we decided that the Plan does 
not have to pre-approve a bone graft (D6014).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the flow cytometry (88189) provided on March 6, 2023. 
 
You asked the Plan to pay for the flow cytometry. You say that you did not request this test and, were unaware 
that it was not covered by your insurance, and if you had been aware of this fact, you would not have agreed to 
it. You also say that you assume your doctor had valid medical reasons for requesting this test. The Plan denied 
your request. The Plan says that iron deficiency and / or anemia is not listed on covered diagnoses for the 
performance of flow cytometry. The Plan also says that you are not anemic or leukopenic. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the flow cytometry by a contract provider. The file does not show that the Plan provided 
notice that the flow cytometry would not be covered. Under Medicare rules, this means the flow cytometry is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the flow cytometry 
(88189) provided on March 6, 2023.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on August 23, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
disagree with the denial and would like for the plan to reconsider payment. The Plan denied your request. The 
Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 23, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L1971) and (L3170) provided on March 1, 
2022.  
 
You asked the Plan to pay for the foot orthotics. You say that the supporting documents support the need for 
the foot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L1971) and (L3170) 
provided on March 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 12, 
2023, to February 10, 2023. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the enrollee did not meet the criteria for SNF services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from January 12, 2023, to February 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second computed tomography (CT) scan of the head 
rendered on February 10, 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 claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 10, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for a second computed tomography (CT) scan of the head 
rendered on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on April 14, 2023. 
 
You asked the Plan to waive the copayment for office visit. You say that you say that you like a refund because 
you did not receive relief from the visit. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for office visit. This item/service falls within the urgently needed 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for office visit provided on 
April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy treatments (97039) provided on  
April 25, 2023 and May 2, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the physical therapy treatments (97039) provided on April 25, 2023 and 
May 2, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee requires electrical stimulation 
(e-stim) until she can participate in more intense therapy. The Plan denied your request. The Plan says the 
requested services are not medically reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the patient has been receiving ongoing physical therapy and as of May 
30, 2023, was independent with ambulation and performing a home exercise program. Therefore, the physical 
therapy dated May 30, 2023, would be considered medically necessary but physical therapy after this would 
not be since the patient can continue with a home exercise program. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy (PT) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided on April 29, 
2022. 
 
You asked the Plan to pay for a porcelain/ceramic crown (D2740). You say that you made two calls to the Plan 
to check coverage on the member. You also say you were told that coverage for crowns would be paid at 50%. 
The Plan denied your request. The Plan says this procedure is not covered under your dental 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, 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 a 
porcelain/ceramic crown (D2740) provided on April 29, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee 
osteoarthritis. She has not tried and failed the Plan's required drugs, Hyalgan, Orthovisc, or Supartz. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc is not 
reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections on April 04, 2022.  
 
You asked the Plan to waive the coinsurance for injections. You say that you want to appeal the amount being 
charged. 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 20% 
coinsurance for Medicare-covered Part B medications, including, but not limited to, chemotherapy and drugs 
used during outpatient diagnostic procedures. Covered drugs include drugs that usually arent self-administered 
by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory 
surgical center services. The provider billed in the amount of $5,760 and the allowed amount is $2,340 for the 
service. $2,340 x 20% = $468. Therefore, results in the total cost sharing amount of $468. You have been asked to pay a 20% coinsurance for injections. This item/service falls within the Medicare Part 
B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for injections on April 
04, 2022.