Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided on June 14, 2023. 
 
You asked the Plan to pay for initial hospital care (99223). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for initial hospital care (99223) provided on June 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field examination (92082) provided on May 31, 
2023. 
 
You asked the Plan to pay for a visual field examination (92082). You say that you went to see a surgeon 
regarding eye lid surgery. You also say the provider said that the Plan would likely require a visual field test. 
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 $35 
copayment for specialist's office visit.  
 
You have been asked to pay a $35 copayment for a visual field examination (92082). This item/service falls 
within the specialist's office 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 pay for a visual field examination 
(92082) provided on May 31, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an esophagogastroduodenoscopy (EGD). 
 
You asked the Plan to pre-approve an EGD. You say that the services are necessary. The Plan denied your 
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 an EGD. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has worsening of chronic heartburn symptoms, so an upper endoscopy is medically 
indicated and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EGD have been met. Therefore, we decided that the Plan has to pre-approve 
an esophagogastroduodenoscopy (EGD).  
 
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 pay for an intraoral x-ray (D0210) provided on June 21, 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 July 1, 2021. Therefore, 
we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the comprehensive orthodontic treatment (D8090). 
 
You asked the Plan to pre-approve the dental service. You say that you had a surgical procedure which resulted 
in additional care. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because the comprehensive orthodontic treatment is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
comprehensive orthodontic treatment (D8090).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator provided on April 15, 2023. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you have an 18% coinsurance. 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 $750 plan deductible, for each Medicare-covered durable medical 
equipment item. 
 
The item or service you asked the Plan to pay for falls within the durable medical equipment (DME) and 
related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $750 deductible which applies to durable medical equipment (DME) and related supplies. This 
cost sharing is a contractual obligation that had not been met at the time the oxygen concentrator was received 
on April 15, 2023. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator 
provided on April 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay on February 09, 
2022, to March 04, 2022.  
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you never requested a 
private room. 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 $275 
copayment per day for days 1-5 and a $0 copayment per day for days 6-90 for Medicare-covered services for 
inpatient hospital care. The enrollee was previously charged $825 for three inpatient hospital days on January 
3, 2022, to January 6, 2022. 
 You have been asked to pay a $275 copayment for days one to five of the inpatient hospital stay. You have 
been asked to pay a total of $550 ($275 copayment x 2 days = $550). You have not been charged for the day 
you were discharged. 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. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient hospital stay on February 09, 2022, to March 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-ray (D0210) provided on May 11, 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 March 6, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral x-ray (D0210) provided on May 11, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an injection provided on February 8, 2023. 
 
You asked the Plan to reduce the cost share for an injection. You say that you disagree with the cost share 
applied. 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 $400 deductible which applies to Medicare Part B prescription drugs 
and 2% coinsurance for Medicare Part B prescription drugs after the deductible has been met. 
 
 
  The total you have been asked to pay is $367.47 for an injection. This total includes a $364.34 deductible and 
$3.13 coinsurance, which is 2% of the allowed amount for a Medicare Part B drug injection ($520.62 allowed  
364.34 deductible = $156.28 remaining x 2% = $3.13). The item or service you asked the Plan to reduce the 
cost share for falls within the Medicare Part B prescription drugs benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $400 deductible which applies to Medicare 
Part B prescription drugs. This cost sharing is a contractual obligation that had not been met at the time an 
injection was received on February 8, 2023. Your deductible was met with the processing of this claim, at 
which time the Plan applied the coinsurance according to your contract. Therefore, we decided that the Plan 
does not have to reduce the cost share for an injection provided on February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling and crown (D2750, D2331) provided on March 23, 
2022. 
 
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 the claim was 
filed untimely. 
 
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 the dental services was not filed until August 2, 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 a filling and crown (D2750, D2331) provided on March 23, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vabysmo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the plan's required drug would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7210) for tooth #2, #3, #11, #13, #14, 
#20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30. 
 
You asked the Plan to pre-approve the dental services. You say that you had a fall, and the dental services 
should be covered under your medical benefit. The Plan denied your request. The Plan says your annual dental 
maximum benefit for the year 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. 
 
The requested teeth extractions in dispute meets the Medicare definition of dental, since it is a service which 
involved the care and treatment of teeth or structures directly supporting the teeth. The extractions do not fall 
under any of Medicare exceptions for coverage of non-routine dental care. Though the Plan offers a dental 
benefit in excess of Medicare coverage, certain limitations apply. The record shows the Plan pre-approved 
$2,000 for dental services on July 29, 2023; therefore, your annual dental maximum benefit for the year of 
2023 was exhausted on the date of approval of July 29, 2023. Therefore, we decided that the Plan does not have 
to pre-approve an extraction (D7210) for tooth #2, #3, #11, #13, #14, #20, #21, #22, #23, #24, #25, #26, #27, 
#28, #29, and #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy services provided on May 4, 2023. 
 
You asked the Plan to pay for endodontic therapy services. You say that you were told a portion of your bill 
would be paid. The Plan denied your request. The Plan says the rendered dental services are not covered 
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 
endodontic therapy services provided on May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary/mandibular complete dentures (D5110, D5120) 
provided on May 5, 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 dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for maxillary/mandibular complete dentures (D5110, D5120) provided on May 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pin retention (D2951) provided on May 11, 2023. 
 
You asked the Plan to pay for pin retention. You say that your mouth was in a lot of pain and bleeding, so this 
was medically necessary. The Plan denied your request. The Plan says this 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 pay for pin 
retention (D2951) provided on May 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the anesthesia services provided on May 4, 
2023, and May 11, 2023. 
 
You asked the Plan to waive the deductible for the anesthesia services. You say that this service should be fully 
covered. 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 $600 deductible which applies to outpatient surgery, including 
services provided at ambulatory surgical centers. 
 
 
 
 You have been asked to pay $120.48 towards your deductible for the anesthesia services provided on May 4, 
2023. You have also been asked to pay $100.40 towards your deductible for the anesthesia services provided 
on May 11, 2023. The items or services you asked the Plan to waive the deductible for fall within the outpatient 
surgery, including services provided at ambulatory surgical centers benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $600 deductible which applies to outpatient 
surgery, including services provided at ambulatory surgical centers. This cost sharing is a contractual 
obligation that had not been met at the time the anesthesia services was received on May 4, 2023, to May 11, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for the anesthesia services 
provided on May 4, 2023, and May 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from May 29, 2023, to June 
17, 2023. 
 
You asked the Plan to pay for the medication. You say that you would like to appeal due to the enrollee's 
incapacity at the time to responsibly take the medication provided. The Plan denied your request. The Plan says 
the medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from May 29, 2023, to June 17, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for an eye examination, an eye refraction, bifocal lens, 
and contact lenses provided on June 12, 2023. 
 
You asked the Plan to reimburse for an eye examination, an eye refraction, bifocal lens, and contact lenses. 
You say that you have a history with this provider. You also say that although he is out-of-network, you have 
chosen to stay with him because of his experience with your eye condition. The Plan denied your request. The 
Plan says services rendered by an out-of-network provider are not covered by the Plan under any normal 
circumstances. 
 
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 by an in-network vision provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one pair of standard lenses and 
frames every year. The Plan rules say that you are responsible for all eyewear costs from providers outside of 
the Plan vision network. Based on this information, we decided that the Plan's rules for coverage of an eye 
examination, an eye refraction, bifocal lens, and contact lenses have not been met. Therefore, we decided that 
the Plan does not have to reimburse for an eye examination, an eye refraction, bifocal lens, and contact lenses 
provided on June 12, 2023.
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 the requested compression 
stockings are medically necessary. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine test provided on June 7, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the urine test. You say that the enrollee did not go out-of-network. 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 item/service 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 this item/service. Therefore, 
we decided that the Plan does not have to pay for the urine test provided on June 7, 2023, by an out-of-network 
(OON) provider.