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

 
We decided that the Plan does not have to pay for deluxe frames (V2025) and progressive lenses (V2781) 
provided on March 31, 2023. 
 
You asked the Plan to pay for deluxe frames (V2025) and progressive lenses (V2781). You say that you are 
requesting the reimbursement because the optometrist's price for one pair of glasses was going to cost over 
$500. The Plan also says that you received 2 pairs of glasses plus prescription sunglasses for $500 from this 
provider. The Plan denied your request. The Plan says the services were from a provider who is not in our 
network. 
 
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 eyewear is obtained through the Plan's vision vendors. 
 
We looked at the file and the Plan's rules. The Plan rules say that routine eye examinations and eyewear must 
be obtained from a provider in the Plan vendor network. The Plan rules also say that services obtained from 
vendors outside this network are not covered. Based on this information, we decided that the Plan's rules for 
coverage of deluxe frames (V2025) and progressive lenses (V2781) have not been met. Therefore, we decided 
that the Plan does not have to pay for deluxe frames (V2025) and progressive lenses (V2781) provided on 
March 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 23, 
2023, through May 24, 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 the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee had an ambulatory surgery and was not a high risk for complications requiring 
inpatient management. The review has determined that the record did not show that at the time of the inpatient 
admission the admitting physician reasonably expected that the enrollees necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 
 
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 pay for the acute inpatient hospital care provided from May 23, 2023, through May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement grafts for ridge preservation-per site 
(D7953 x 2), interim partial denture (D5821), and the surgical placement of an implant body: endosteal 
implants (D6010 x 2) provided on May 26, 2022 and August 29, 2022. 
 
You asked the Plan to pay for these items/services. 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/services at issue are 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 items/services provided are not 
among those covered under this benefit.   
 
 
 
 
Therefore, we decided that the Plan does not have to pay for the bone replacement grafts for ridge preservation-
per site (D7953 x 2), interim partial denture (D5821), and the surgical placement of an implant body: endosteal 
implants (D6010 x 2) provided on May 26, 2022 and August 29, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration for 
the services provided. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 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 skilled nursing facility care provided on 2023, by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on March 10, 2023. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you say that you were led to believe 
that non radiological diagnostic had a $20 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for ultrasound provided on March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory scrape testings provided on April 17, 2023. 
 
You asked the Plan to pay for laboratory scrape testings. You say that the lab has no responsibility with getting 
authorization. Please see records and reconsider. 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 laboratory scrape 
testings provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on February 21, 2023. 
 
You asked the Plan to pay 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 hearing aids at issue in this case 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 hearing aids are only covered when purchased from the Plans select 
hearing aid provider. However, the hearing aids in this case were rendered by an out-of-network provider. 
Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) provided on February 21, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye injections, a neodent implant, a neodent abutment, lower 
complete dentures and upper complete dentures provided from March 4, 2023, to March 10, 2023. 
 
You asked the Plan to pay for eye injections, a neodent implant, a neodent abutment, lower complete dentures 
and upper complete dentures. You say that you got services while in a different country. You also say you are 
trying to get the reimbursement processed. The Plan denied your request. The Plan says you do not have non-
emergency worldwide services as a covered benefit under your Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover services outside of the 
United States. Items and services furnished outside the United States are excluded from coverage with limited 
exceptions. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 60.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of eye injections, a neodent implant, a neodent abutment, lower complete dentures and upper 
complete dentures have not been met. Therefore, we decided that the Plan does not have to pay for eye 
injections, a neodent implant, a neodent abutment, lower complete dentures and upper complete dentures 
provided from March 4, 2023, to March 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the dental 
cleaning (D1110) provided on May 11, 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 you do not meet criteria for coverage of the 
services provided.  
 
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.  
 
  
 
 
 
 
We looked at this case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the dental services provided in this case were not 
rendered by your assigned dental provider. The Plans contract states that in order for services to be covered, 
members must receive dental care from their assigned dentist. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral evaluation (D0150) and the dental cleaning (D1110) provided on  
May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reline complete maxillary denture (D5750) provided on 
February 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing with supporting records. 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 June 6, 2022. Therefore, 
we decided that the Plan does not have to pay for reline complete maxillary denture (D5750) provided on 
February 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy provided on April 27, 
2023. 
 
You asked the Plan to pay for the esophagogastroduodenoscopy. 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 the 
esophagogastroduodenoscopy provided on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extremity veins provided on May 05, 2023. 
 
You asked the Plan to pay for duplex scan of extremity veins. You say that you are asking for medical records 
to be reviewed. 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 duplex scan of extremity 
veins provided on May 05, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, and psychotherapy services provided on June 
20, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit, and psychotherapy services. You say that this is supported in the 
records. The Plan denied your request. The Plan says enrollees must receive their care from 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 
items/services 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 office visit, and psychotherapy services 
provided on June 20, 2023, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services. 
 You asked the Plan to pre-approve home health services. You say that it is medically necessary for you to get 
physical therapy. The Plan denied your request. The Plan says the services are not medically necessary. Also, 
outpatient therapy has been approved.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee has a medical history of chronic shoulder and knee pain as well as lumbar spine pain. Clinical 
documentation dated June 29, 20203, indicated that the enrollee has a medical history of thoracic spinal fusion 
and osteomyelitis, scoliosis, cirrhosis, and muscle weakness. The enrollee was noted to have tenderness to 
palpation of the lumbar spine and a positive straight leg raise test. The enrollee was referred to ambulatory 
physical therapy, neurosurgery clinic and pain management. 
 
The enrollee has a medical history of thoracic spinal fusion likely due to scoliosis and osteomyelitis. The 
enrollee is noted to have chronic pain affecting the shoulder and knee joints and lumbar spine. While physical 
therapy would be indicated for these conditions, it is unclear why the enrollee requires home health physical 
therapy versus outpatient physical therapy, for which he was referred in the outpatient clinical documentation 
dated June 29, 2023. There is insufficient documentation indicating that the enrollee his homebound and 
requires home health physical therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on May 24, 2023. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary. 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 drug testing provided on 
May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital visit provided on April 26, 2023. 
 
You asked the Plan to pay for outpatient hospital visit. You say that you are asking for the medical records to 
be reviewed. 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 outpatient hospital visit 
provided on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92004) and a determination of 
refractive state (92015) provided on December 16, 2022. 
 
You asked the Plan to pay for a medical eye examination (92004) and a determination of refractive state 
(92015). You say that the enrollee has active coverage and a $30 copayment for in-network specialist office 
visits. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a medical eye 
examination (92004) and a determination of refractive state (92015) provided on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on June 01, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you say that your PCP advised you 
that there was an issue with your ear and you went to get a hearing exam and you feel that you should not be 
charged a copay. 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 $15 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $15 copayment for an office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on June 01, 2023.