Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor and receiver. 
 
You asked the Plan to pre-approve the Dexcom G7 sensor and receiver. The Plan denied your request. The Plan 
says the Dexcom G7 is a non-preferred brand, and the medical need has not been met because the records do 
not show that the enrollee has tried one of the preferred brands and it did not help. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Dexcom G7 sensor and receiver. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G7 sensor and receiver.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99214) and the scanning of 
computerized ophthalmic diagnostic imaging (92133) provided on June 20, 2023. 
 
You asked the Plan to pay for a specialist office visit (99214) and the scanning of computerized ophthalmic 
diagnostic imaging (92133). You say that the Plan denied as no authorization. You also say that you would like 
the submitted records reviewed and paid accordingly. 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 specialist office visit 
(99214) and the scanning of computerized ophthalmic diagnostic imaging (92133) provided on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 6, 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 June 02, 2023, Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 6, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a retroperitoneal ultrasound provided on 
June 28, 2023. 
 
You asked the Plan to reduce the copayment for a retroperitoneal ultrasound. You say that you thought that the 
copayment would be lower. 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 $80 
copayment for other Medicare-covered radiological diagnostic services, including ultrasounds. 
 
You have been asked to pay a $80 copayment for a retroperitoneal ultrasound. This item/service falls within the other Medicare-covered radiological diagnostic services, including ultrasounds 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. However, since the allowed amount is 
less than the standard copayment, you only owe $56.69. Therefore, we decided that the Plan does not have to 
reduce the copayment for a retroperitoneal ultrasound provided on June 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of an intraosseous basivertebral 
nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral (64628). 
 
  
 
 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service.  
 
The Plan follows Medicare rules. Medicare rules say that thermal destruction of the intraosseous basivertebral 
nerve (BVN) will be considered medically reasonable and necessary for the treatment of chronic low back pain 
(cLBP) in patients who meet ALL of the indicated criteria.  
 
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 this service. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested service. Our physician reviewer found that there is 
no magnetic resonance imaging (MRI) showing only modic changes without facet joint degenerative disease or 
stenosis. The cause of pain is not clear.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of an intraosseous basivertebral nerve, including all imaging guidance; 
first 2 vertebral bodies, lumbar or sacral (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided by an in-network 
provider on June 15, 2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that this was an annual wellness 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. Your 
contract with the Plan says that there is a $250 in and out-of-network deductible which applies to the office 
visit. 
 
 
 
 
 
 You have been asked to pay a $61.69 deductible for the office visit. The item or service you asked the Plan to 
waive the deductible for falls within the physician/practitioner services, including doctors office visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 in and 
out-of-network deductible which applies to physician/practitioner services, including doctors office visits. This 
cost sharing is a contractual obligation that had not been met at the time the office visit was provided on June 
15, 2023. Therefore, we decided that the Plan does not have to waive the deductible for the office visit 
provided by an in-network provider on June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 22, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on August 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart catheterization and ventriculography (93458). 
 
You asked the Plan to pre-approve heart catheterization and ventriculography. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve heart catheterization and 
ventriculography. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee does not benefit from an invasive cardiac 
catheterization due to lack of angina, significant arrhythmia, or heart failure and with minimally abnormal 
nuclear stress test.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of heart catheterization and ventriculography have not been met. Therefore, we 
decided that the Plan does not have to pre-approve heart catheterization and ventriculography (93458).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee lives alone and needs 
LTACH services to be able to improve their function. You also say the type of care the enrollee will receive at 
an LTACH may not be offered at other facilities/settings. The Plan denied your request. The Plan says 
admission to an LTACH is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation indicating medical necessity for admission to an 
LTACH. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve acupuncture treatments. You say that you were referred to this provider and 
that's who you want to see. The Plan denied your request. The Plan says there are other providers available who 
are in-network, who are within the Medicare allowable distance from your residence. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture treatments to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
May 24, 2023, to May 25, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you were advised 
not to pay the copayment because the hospital did not do their job. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
(ER) visit provided on May 24, 2023, to May 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on May 15, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration stating you have 
attached the complete lab test results and other supporting documents for review. 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 lab testing provided on 
May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an intraoral x-ray and crown (D0220, D2740) provided 
on June 12, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says 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 an intraoral x-ray and crown (D0220, 
D2740) provided on June 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on 
February 27, 2023, to March 21, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you disagree with the 
denied claim. 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 $200 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $200 copayment for inpatient hospital services. This item/service falls within the 
Inpatient hospital 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. You have been asked to a total of $1,000 for inpatient hospital stay ($200 copayment x 5 
days = $1,000) Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital 
services provided on February 27, 2023, to March 21, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services on June 9, 2023, to June 28, 2023. 
 You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 9, 2023. The NOA was not received by the Plan until September 19, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services on June 
9, 2023, to June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5261) provided on March 2, 2022. 
 
You asked the Plan to reimburse for hearing aids (V5261). You say that you were not aware that you needed to 
use the other company. The Plan denied your request. The Plan says you must use a Plan hearing vendor 
provider to use this benefit. 
 
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 you obtain the hearing aids from a Plan hearing network vendor. 
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5261) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5261) provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750), polycarbonate lenses 
(V2784), tint (V2745), deluxe frames (V2025), and  progressive lenses (V2781) provided on May 18, 2023. 
 
You asked the Plan to pay for anti-reflective coating (V2750), polycarbonate lenses (V2784), tint (V2745), 
deluxe frames (V2025), progressive lenses (V2781), and a routine eye examination including refraction 
(S0620, 92015) provided on May 18, 2023. You say that you were sent information by the Plan encouraging 
you to buy new eyeglasses. You also say you were told repeatedly by the provider that costs were covered. The 
Plan denied your request. The Plan says the benefit was 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  $250 benefit toward the purchase and fitting of eyeglasses and pair of lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $250 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses. The Plan rules also say you pay any amount over the $250 retail 
price. The record also shows that this benefit was exhausted with this date of service. Based on this 
information, we decided that the Plan's rules for coverage of anti-reflective coating (V2750), polycarbonate 
lenses (V2784), tint (V2745), deluxe frames (V2025), progressive lenses (V2781), and a routine eye 
examination including refraction (S0620, 92015) provided on May 18, 2023. have not been met. Therefore, we 
decided that the Plan does not have to pay for anti-reflective coating (V2750), polycarbonate lenses (V2784), 
tint (V2745), deluxe frames (V2025), and  progressive lenses (V2781) provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on July 6, 
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 a 
mandibular partial denture (D5214) provided on July 6, 2023.