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

 
We decided that the Plan does not have to pay for deluxe frames and progressive lenses provided on March 16, 
2023. 
 
You asked the Plan to pay for deluxe frames and progressive lenses. You say that a Plan representative told you 
that although out-of-network was used for your glasses, the Plan would reimburse a standard amount. The Plan 
denied your request. The Plan says the benefit Plan does not cover this out-of-network vision care service or 
material. 
 
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 services are obtained through a Plan vision vender network 
provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that non-Medicare covered routine eye 
examinations and eyewear must be obtained from a provider in the Plan's vision vendor network. 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 and progressive lenses have not been met. Therefore, we decided 
that the Plan does not have to pay for deluxe frames and progressive lenses provided on March 16, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 23, 2023, 
through February 25, 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 that 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was evaluated in the emergency department (ED) and admitted with a possible upper 
gastrointestinal bleed. She was evaluated by Gastroenterology and underwent an upper endoscopy. The 
endoscopy revealed esophagitis and gastritis. She was treated with intravenous fluids and intravenous proton 
pump inhibitor (PPI) medication. Her condition stabilized and improved. She tolerated an oral diet and was 
discharged back to the nursing facility on February 25, 2023. The review has determined that the record 
showed that at the time of the inpatient admission it was reasonable for the admitting physician to expect that 
the enrollees necessary hospital care (including earlier ED and/or observation care) would span two midnights 
with supporting documentation of the enrollees history and comorbidities, signs and symptoms, current 
medical needs, and risk of an adverse event. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from February 23, 2023, through February 25, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied dental services and that the services requested are medically necessary. 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 July 26, 2022. Therefore, 
we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), an adult prophylaxis 
(D1110), and bitewings (D0274) provided on June 29, 2022. 
 
You asked the Plan to pay for comprehensive oral evaluation (D0150), an adult prophylaxis (D1110), and 
bitewings (D0274). You say that this claim was submitted three times by the provider on June 29, 2022, July 
28, 2022, and July 11, 2023. You also say you would like the Plan to pay this claim. The Plan denied your 
request. The Plan says this claim was received after timely filing limitations. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for comprehensive oral evaluation (D0150), an adult prophylaxis (D1110), and 
bitewings (D0274) was not filed until July 6, 2023. This means that more than one calendar year from the date 
of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for 
comprehensive oral evaluation (D0150), an adult prophylaxis (D1110), and bitewings (D0274) provided on 
June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided on August 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 an 
extraction (D7210) provided on August 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns (D2740) provided on February 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 28, 2023. 
Therefore, we decided that the Plan does not have to pay for crowns (D2740) provided on February 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve additional routine transportation services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says you have exhausted your annual benefit. 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bifocal lenses (V2200) and miscellaneous vision item or 
service (V2799) provided on June 3, 2023.  
You asked the Plan to pay for bifocal lenses (V2200) and miscellaneous vision item or service (V2799). You 
say that the provider never told you that they were out-of-network until they were done. You also say that you 
have not gotten new glasses in years, and fell it should be covered. The Plan denied your request. The Plan says 
the claim is from a provider who is not in their 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 a Plan vision provider.. 
 
We looked at the file and the Plan's rules. The Plan rules say there is a $200 limit for eyewear every year from 
a Plan vision provider. Based on this information, we decided that the Plan's rules for coverage of bifocal 
lenses (V2200) and miscellaneous vision item or service (V2799) have not been met. Therefore, we decided 
that the Plan does not have to pay for bifocal lenses (V2200) and miscellaneous vision item or service (V2799) 
provided on June 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the foot orthotics (L3000).  
 
You asked the Plan to pre-approve the foot orthotics. You say that you have Charcot foot disease and the 
inserts will help you live a more ambulatory life with less pain. 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 pre-approve the foot orthotics (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup. You say that your tooth needs to be filled or capped. The Plan 
denied your request. The Plan says this service is not a covered expense 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 pre-approve core 
buildup (D2950).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a positron emission tomography (PET) 
scan provided on June 01, 2023. 
 
You asked the Plan to waive the coinsurance for a positron emission tomography (PET) scan. You say that you 
were not informed of the cost share prior to the service rendered and have no means to pay for the service. 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 40% 
coinsurance for outpatient diagnostic tests. 
 
You have been asked to pay 40% coinsurance for a positron emission tomography (PET) scan. This 
item/service falls within the outpatient diagnostic tests 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. You have been asked to pay $653.62 coinsurance, which is 
40% of the allowed amount for an out-of-network PET scan ($1,634.05 allowed x 20% = $653.62). Therefore, 
we decided that the Plan does not have to waive the coinsurance for a positron emission tomography (PET) 
scan provided on June 01, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health services. 
 
You asked the Plan to pre-approve home health services. You say that the enrollee has major neurocognitive 
disorder secondary to Alzheimers dementia and requires assistance with all activities of daily living skills. The 
Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the home 
health services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network endoscope (EGD) provided 
on August 01, 2023. 
 
You asked the Plan to waive the copayment for an in-network endoscope (EGD). You say that this is a large 
amount of money and you cannot afford it. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Outpatient surgery, including services provided athospital outpatient facilities and ambulatory 
surgicalcenters.  
You have been asked to pay a $250 copayment for an in-network endoscope (EGD). This item/service falls 
within the Outpatient surgery, including services provided athospital outpatient facilities and ambulatory 
surgicalcenters 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 in-network endoscope 
(EGD) provided on August 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for photochromatic tint (V2744), lenses (V2782), 
spherocylinder, trifocal, plano to plus or minus 4.00 diopter (d) sphere, 4.25 to 6.00 cylinder lens (V2305), 
Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25-4.00d cylinder lens (V2304), prisms 
(V2715) and anti-reflective coating (V2750) provided on February 20, 2023. 
 
You asked the Plan to pay for photochromatic tint (V2744), lenses (V2782), spherocylinder, trifocal, plano to 
plus or minus 4.00 diopter (d) sphere, 4.25 to 6.00 cylinder lens (V2305), Spherocylinder, trifocal, plano to 
plus or minus 4.00d sphere, 2.25-4.00d cylinder lens (V2304), prisms (V2715) and anti-reflective coating 
(V2750). You say that you had to get re-tested again because something was wrong from the first time you had 
your eyes checked. You also say that you are not happy with the status of your eyeglasses and may call the 
provider to return them within 90 days. The Plan denied your request. The Plan says this benefit has been 
exhausted. 
 
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 up to a total of $250 every 2 years for eyeglasses from participating network 
providers. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan pays up to a total of $250 every 2 
years for eyeglasses from participating network providers. You are responsible for costs above the Plan limit. 
The record shows the benefit was exhausted with this date of service. Based on this information, we decided 
that the Plan's rules for coverage of photochromatic tint (V2744), lenses (V2782), spherocylinder, trifocal, 
plano to plus or minus 4.00 diopter (d) sphere, 4.25 to 6.00 cylinder lens (V2305), Spherocylinder, trifocal, 
plano to plus or minus 4.00d sphere, 2.25-4.00d cylinder lens (V2304), prisms (V2715) and anti-reflective 
coating (V2750) have not been met. Therefore, we decided that the Plan does not have to pay for 
photochromatic tint (V2744), lenses (V2782), spherocylinder, trifocal, plano to plus or minus 4.00 diopter (d) 
sphere, 4.25 to 6.00 cylinder lens (V2305), Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25-
4.00d cylinder lens (V2304), prisms (V2715) and anti-reflective coating (V2750) provided on February 20, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T). 
 
You asked the Plan to pre-approve transurethral waterjet ablation of prostate. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that transurethral waterjet ablation of prostate is covered 
when specific criteria are met.  
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 transurethral waterjet ablation of 
prostate. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
enrollee does not meet the coverage criteria detailed in the LCD. Aquablation is not yet approved for the 
treatment of prostate cancer. In addition, the records do not show that the enrollee has a maximum urinary flow 
rate (Qmax) of =15 mL/s4 (voided volume greater than 125 cc) or failure, contraindication or intolerance to at 
least 3 months of conventional medical therapy for LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, 
finasteride/dutasteride). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate (0421T).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on May 24, 2023, to June 22, 
2023. 
 
You asked the Plan to pay for occupational therapy. You say that you are requesting a 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 occupational therapy 
provided on May 24, 2023, to June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided on August 7, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had to urgently see an in-network provider 
for an oral evaluation as you could not wait until you were back home. The Plan denied your request. The Plan 
says your benefit for the requested comprehensive oral evaluation 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 service was exhausted on date of service April 12, 2021.  Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150) provided on August 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment and manual therapy 
provided on January 23, 2023, to February 27, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the chiropractic manipulative treatment and manual therapy. You say that you 
just found out that the chiropractor was not in service and would like the claim to be reprocessed. The Plan 
denied your request. The Plan says that the chiropractic manipulative treatment and manual therapy is available 
in network. 
 
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 the chiropractic manipulative treatment and 
manual therapy provided on January 23, 2023, to February 27, 2023, by an out-of-network (OON) provider.