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

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on July 12, 2023. 
 
You asked the Plan to pay for the office visit. You say that it was your understanding that the services were 
covered under your insurance except the copay. The Plan denied your request. The Plan says the only covered 
chiropractic service is manual manipulation of the spine. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on July 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 5, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 5, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that you are trying to get your dentures 
approved or a part of it. The Plan denied your request. The Plan says these services are not covered in your 
dental benefit. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete 
denture - maxillary (D5110), and complete denture - mandibular (D5120).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (99283) provided on July 10, 
2023. 
 
You asked the Plan to pay for the ER visit. 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 the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an emergency room (ER) visit (99283) 
provided on July 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that the requested custom orthotics are medically 
necessary for the enrollee. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99214) and a determination of a 
refractive state (92015) provided on March 21, 2023. 
 
You asked the Plan to pay for a specialist office visit (99214) and a determination of a refractive state (92015). 
You say that you are having problems with your eyes. You also say that you told the provider that you already 
have had your examination, but the provider wanted to have it checked out to see if there was a problem. 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 one routine eye examination per calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one routine eye examination per 
calendar year from a Plan ophthalmologist or optometrist in your selected provider system. The record shows 
that this benefit has been exhausted on January 23, 2023. Based on this information, we decided that the Plan's 
rules for coverage of a specialist office visit (99214) and a determination of a refractive state (92015) have not 
been met. Therefore, we decided that the Plan does not have to pay for a specialist office visit (99214) and a 
determination of a refractive state (92015) provided on March 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network comprehensive hearing and 
speech recognition test for inpatient services March 14, 2023, to March 15, 2023. 
 
 
You asked the Plan to waive the deductible for an in-network comprehensive hearing and speech recognition 
test for inpatient services. You say that you should not have to pay this large deductible to pay. 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. Your 
contract with the Plan says that there is a $300 deductible which applies to inpatient hospital care.  
 
The item or service you asked the Plan to waive the deductible for falls within the inpatient hospital care 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 
deductible which applies to inpatient hospital care.  This cost sharing is a contractual obligation that had not been met at the time an in-network comprehensive 
hearing and speech recognition test for inpatient services was received on March 14, 2023 to March 15, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for an in-network comprehensive 
hearing and speech recognition test for inpatient services March 14, 2023, to March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment purchased on March 21, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that you were told you would be reimbursed 
100%. The Plan denied your request. The Plan says the purchased oxygen equipment is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for oxygen equipment 
purchased on March 21, 2023.  
 
Your complaint about receiving bad information from the Plan is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a leg sleeve and 
not a compression sock. The Plan denied your request. The Plan says the requested item is not covered by 
Medicare or the Plan. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
 You asked the Plan to pre-approve the additional trips. You say that the enrollee's treatment includes a 
medication that is a scheduled III drug which requires to not drive for the remainder of the day following 
treatment. The enrollee does not have any other transportation options and must rely on transportation through 
the insurance plan. The Plan denied your request. The Plan says the enrollees benefit does not cover more than 
10 trips per plan year. The record shows the enrollee has used the allowed 10 one-way trips. 
 
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 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional trips for treatment appointments. 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 trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exams provided by a chiropractor on March 22, 
2023. 
 
You asked the Plan to pay for the x-ray exams. You say that the services should be covered under your 
membership. The Plan denied your request. The Plan says that the only covered chiropractic service is manual 
manipulation of the spine. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the x-ray exams provided by a chiropractor on March 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames, the progressive lens, and the anti-
reflective coating provided on June 28, 2023. 
 
You asked the Plan to pay for the deluxe frames, the progressive lens, and the anti-reflective coating. You say 
that the provider indicated that he believed that EyeMed has paid out-of-network claims in the past. You say if 
EyeMed has paid these claims in the past, you feel that you deserve to have your claim paid. The Plan denied 
your request. The Plan says the provider was out-of-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 provided by an in-network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the deluxe frames, the progressive lens, and the 
anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for the 
deluxe frames, the progressive lens, and the anti-reflective coating provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye exam and an ophthalmoscopy on May 
24, 2023.  
 
You asked the Plan to waive the copayment for eye exam and an ophthalmoscopy. You say that you never had 
to pay this 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 $30 
copayment per specialist visit at an outpatient hospital. You must pay a $50 copay for diagnostic 
procedures/tests at an outpatient hospital. The provider billed in the amount of $25 and allowed amount is 
$16.92 for the service. This is less than the copayment amount. For both services it's, $30 + $16.92 = $46.92. 
Therefore, results in total cost sharing amount of $46.92. 
 
You have been asked to pay a $30 copayment for eye exam and a $16.92 copayment which is less than the 
copayment for an ophthalmoscopy. This item/service falls within the outpatient hospital 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 eye exam and an ophthalmoscopy on May 24, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services (99213, 11102, and 17000) provided 
on May 15, 2023. 
 
You asked the Plan to pay for the office visit services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider has opted out of the Medicare 
program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit services (99213, 11102, and 17000) provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service provided on April 10, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory service. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was 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 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 laboratory service provided on April 10, 2023, 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 23, 2023, billed with 
codes 81209, 81216, 81223, 81233, 81238, 81241, 81242, 81249, 81250, 81279, 81298, 81305, 81307, 81311, 
81317, 81320, 81321, 81334, 81345, 81339, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 23, 2023, billed with codes 81209, 81216, 81223, 81233, 81238, 81241, 81242, 81249, 81250, 81279, 
81298, 81305, 81307, 81311, 81317, 81320, 81321, 81334, 81345, 81339, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture treatments. 
 
You asked the Plan to pre-approve the acupuncture services. You say that your acupuncture treatments have 
been working and if more visits are not approved your pain will come back. The Plan denied your request. The 
Plan says that your benefit for acupuncture services has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have used 19 out of your 20 approved visits for 
acupuncture services. After the 20
th
 visit your benefit will be exhausted for the year. Therefore, we decided that 
the Plan does not have to pre-approve additional acupuncture treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FreeStyle Libre reader/monitor and 30 days of sensors 
provided on June 9, 2023. 
 
You asked the Plan to pay for the reader/monitor and sensors. You say that the medical records have been 
submitted for review. The Plan denied your request. The Plan says the documentation requirements have not 
been met. 
 The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the FreeStyle Libre reader/monitor and 30 days of sensors provided on June 9, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on April 4, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the laboratory services based on Medicare criteria. The Plan did not provide the claim at issue to 
verify if it was billed correctly. Additionally, the Plan has not provided the correct Evidence of Coverage for 
this case. Therefore, we decided that the Plan has to pay for the laboratory services provided on April 4, 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 crown- porcelain/ceramic tooth 8 and 9 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that you did not damage your teeth. The Plan denied your 
request. The Plan says replacing tooth structures lost as a result of abrasion, attrition, erosion or abfraction is 
not a covered service. 
 
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 
crown- porcelain/ceramic tooth 8 and 9 (D2740).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277, 99183). 
 
You asked the Plan to pre-approve HBO therapy. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is already improving. 
 
The Plan follows Medicare rules. Medicare rules say that the use of HBO therapy is covered as adjunctive 
therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard 
wound therapy and must be used in addition to standard wound care. 
 
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 HBO therapy. Our reviewer says that 
the requested HBO therapy is not medically necessary. Our physician reviewer found the records show that the 
enrollee had a left groin lymph node excision and has had a non-healing wound; however, the wound has 
decreased in size, meaning HBO therapy is not indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) therapy (G0277, 99183).