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

 
We decided that the Plan does not have to waive the copayment for the office visit, the canalith repositioning 
procedure, and the hearing test provided on August 24, 2023. 
 
You asked the Plan to waive the copayment for the office visit, the canalith repositioning procedure, and the 
hearing test. You say that you do not understand the cost sharing. 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 $45 
copayment for each in-person specialist visit, a $40 copayment for each therapy visit which includes physical 
therapy, occupational therapy, and speech language therapy, and a $5 copayment for diagnostic procedures and 
tests. 
 
You have been asked to pay a $45 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits benefit category. You have been asked to pay a 
$40 copayment for the canalith repositioning procedure. This item/service falls within the outpatient 
rehabilitation services benefit category. You have also been asked to pay a $5 copayment for the hearing test. 
This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the office visit, the canalith repositioning 
procedure, and the hearing test provided on August 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require an IRF admission to regain your full 
level of function. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
an IRF admission and does not have out-of-network benefits.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for multiple therapies, including physical or occupational therapy, there is no documented need for 
intensive rehabilitation services. There is not a reasonable expectation that you will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care 
can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis-adult (D1110) and topical application of fluoride 
(D1206) provided on May 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the prophylaxis-adult has already been exhausted. Topical application of 
fluoride 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, certain limitations apply. The record 
shows your benefit for the prophylaxis-adult was exhausted on date of service January 24, 2023. Topical 
application of fluoride is not a covered service.  Therefore, we decided that the Plan does not have to pay for prophylaxis-adult (D1110) and topical application 
of fluoride (D1206) provided on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on August 16, 2023. 
 
You asked the Plan to pay for the nursing facility care. 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 nursing facility care 
provided on August 16, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0480 provided on July 17, 2023. 
 
You asked the Plan to pay for procedure code G0480. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that code G0480 is bundled into payment for 
code 80307. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS has withdrawn the rule stating that code 
G0480 is bundled into code 80307. Code G0480 is now separately payable from code 80307 in accordance 
with the bulletin that CMS published on its website along with the 2023 Q4 NCCI files.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code G0480 have been met. Therefore, we decided that the Plan has to pay for procedure code 
G0480 provided on July 17, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on April 24, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was a routine eye 
examination, and it has been over 12 months since your last exam. You say you should not be responsible for 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for each Medicare-covered exam.  
 
You have been asked to pay a $15 copayment for the office visit. The office visit falls within the vision care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. The medical record shows diagnoses of astigmatism, hyperopia, presbyopia, and senile cortical cataracts. 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 office visit provided on April 
24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 1, 2022. 
 
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 the claim was not filed timely per Medicare 
guidelines. 
 
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 laboratory services was not filed until June 27, 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 the laboratory services provided on April 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0670). 
 
You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for PCDs 
have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Because the base item is not covered, the related item coded as E0670 is also denied. Therefore, we 
decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0670).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for in-network injections provided on August 
10, 2023. 
 
You asked the Plan to reduce the coinsurance for in-network injections. You say that you have these injections 
every two weeks, and the cost went from $20 to almost $300? This is too much. 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 20% 
coinsurance for Medicare Part B prescription drugs and related supplies. 
 
You have been asked to pay 20% coinsurance for in-network injections. This item/service falls within the 
Medicare Part B prescription drugs and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. The total you owe is $296.70 ($1,483.49 x 20% = $296.70). 
Therefore, we decided that the Plan does not have to reduce the coinsurance for in-network injections provided 
on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025) and progressive lenses (V2781) 
provided on June 12, 2023.  
You asked the Plan to pay for deluxe frames (V2025) and progressive lenses (V2781). You say that when you 
completed your order with this provider, the total was $272, which is under the $300 allowance you have for 
your glasses. You also say that now you have received an email from the Plan saying you owe a balance due to 
them. 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 $300 toward the eyewear purchase. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover up to $300 for eyeglasses or contact 
lenses every year. The record shows that this benefit has been exhausted on this date of service. Specifically, 
the $300 benefit has been applied to this service. The record shows that after the $300 benefit was applied, 
there was also a 20% discount given to the remainder leaving you with a $125.60 balance ($475 retail cost - 
$300 benefit allowance = $157 remaining balance) ($157 - 20% discount = $125.60). Based on this 
information, we decided that the Plan's rules for coverage of deluxe frames (V2025) and progressive lenses 
(V2781) have not been met. Therefore, we decided that the Plan does not have to pay for deluxe frames 
(V2025) and progressive lenses (V2781) provided on June 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided on June 27, 2023. 
 
You asked the Plan to pay for an ankle-foot orthosis. You say that the item at issue was a medical necessity for 
the enrollee. 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 or relevant medical records which support medical 
necessity for the supplies provided in this case. The document provided as proof of delivery does not correspond to the billed date of service. The provided medical records do not discuss the item at issue. 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 an ankle-foot orthosis (L1971) provided on June 
27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on July 13, 2023, to July 17, 2023. 
 
You asked the Plan to pay for the lab testing. You say that the services should be covered. 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 lab testing provided 
on July 13, 2023, to July 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on June 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have been going to the provider for 3 years 
and she was in-network last year. You also say that you and the representative from the dental office have been 
calling and speaking to the insurance and are being told it is a glitch in the system. The Plan denied your 
request. The Plan says your benefit for the requested services 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 services was exhausted on date of service April 19, 2023. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on June 21, 2023.
Appeal type: Supplemental Benefit
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 you need the additional 10 trips for 
appointments you have for the remainder of the year and to pick up your medications.  The Plan denied your 
request. The Plan says the request for a 101st trip, and beyond is not a covered 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 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 10 
additional routine transportation trips for appointments and to pick up your medications. 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 pre-approve a radiofrequency ablation (RFA) of the nerves of the 
sacroiliac joint (64625). 
 
You asked the Plan to pre-approve an RFA of the sacroiliac joint. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that SIJ RFA is not considered reasonable and 
necessary. Based on this information, we decided that Medicare rules for coverage of an RFA of the sacroiliac 
joint have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency 
ablation (RFA) of the nerves of the sacroiliac joint (64625).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary to help the 
enrollee regain strength. The Plan denied your request. The Plan says the IRF services requested do not meet 
the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical additional radiographic images 
(D0230 x 2) provided on July 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided was exhausted on date of service July 26, 2023.  
  
 
Specifically, the Plans contract states that intraoral x-rays are covered once per calendar year. On this day, you 
received three intraoral x-rays, in which one was paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for the services provided in this case. Therefore, we decided that the Plan does not have to 
pay for the intraoral-periapical additional radiographic images (D0230 x 2) provided on July 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000).  
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit for your condition.  
 
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 foot orthotics (L3000).