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

 
We decided that the Plan does not have to pay for telehealth services provided on July 05, 2023. 
 
You asked the Plan to pay for telehealth services. You say that you are requesting reconsideration for 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 telehealth services 
provided on July 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on August 
18, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that Original Medicare would 
have paid for the claim. The Plan denied your request. The Plan says that the chiropractic manipulative 
treatment is available in network.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment provided 
on August 18, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750), bifocal lenses (V2200) and 
frames (V2020) provided on August 5, 2023. 
 
You asked the Plan to pay for anti-reflective coating (V2750), bifocal lenses (V2200) and frames (V2020). You 
say that you paid $60 out of your own pocket for services that were not allowed. You also say you did not 
exceed anything. 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 a $300 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 they offer a $300 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses. The Plan rules also say you are responsible for any amount over the 
$300 retail price. The record shows that this benefit has been exhausted on this date of service. Based on this 
information, we decided that the Plan's rules for coverage of anti-reflective coating (V2750), bifocal lenses 
(V2200) and frames (V2020) have not been met. Therefore, we decided that the Plan does not have to pay for 
anti-reflective coating (V2750), bifocal lenses (V2200) and frames (V2020) provided on August 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a partial upper denture (D5225) provided by an out-of-
network provider on June 7, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you spoke with the Plan and you were 
assured the appliance would be covered 100%. 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. Also, it was verified that the provider called and it was confirmed that they 
were 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. 
 
  The total amount billed for the partial upper denture (D5225) was $2,209 and the total allowed amount was 
$803 leaving a difference of $1,406 ($2,209 billed - $803 allowed). 
 
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 a partial upper denture (D5225) provided by 
an out-of-network provider on June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for anti-reflective coating (V2750), polycarbonate lenses 
(V2784), deluxe lens feature (V2702), progressive lenses (V2781), and frames (V2020) provided on July 26, 
2023. 
 
You asked the Plan to reimburse for anti-reflective coating (V2750), polycarbonate lenses (V2784), deluxe lens 
feature (V2702), progressive lenses (V2781), and frames (V2020). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says because the provider is out-of-network with 
your Plan, and because there is not coverage when services are rendered by a non-participating provider, the 
Plan will maintain its initial determination to not pay for the submitted claim. 
 
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 eyeglasses are obtained from a Plan vision network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $200 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses. The Plan rules also say that any benefits received at a non-network 
optical provider are excluded from this benefit. Based on this information, we decided that the Plan's rules for 
coverage of anti-reflective coating (V2750), polycarbonate lenses (V2784), deluxe lens feature (V2702), 
progressive lenses (V2781), and frames (V2020) have not been met. Therefore, we decided that the Plan does 
not have to reimburse for anti-reflective coating (V2750), polycarbonate lenses (V2784), deluxe lens feature 
(V2702), progressive lenses (V2781), and frames (V2020) provided on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 21, 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 $350 annual maximum 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 $350 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay for 
dental services provided on August 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation (D0367) provided 
on March 6, 2023. 
 
You asked the Plan to pay for cone beam CT capture and interpretation. You say that this should be covered. 
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 cone 
beam CT capture and interpretation (D0367) provided on March 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI of the lumbar spine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found medical necessity of 
the MRI without a 6-week trial of physical therapy has not been established. 
 
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 MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical eye examination and evaluation with initiation of 
diagnostic and treatment program (92004) provided on February 02, 2023. 
 
You asked the Plan to pay for medical eye examination and evaluation with initiation of diagnostic and 
treatment program (92004). You say that you were under the impression that you were in-network. You also 
say that you saw this patient in good faith that the claim would be paid. 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 medical eye examination 
and evaluation with initiation of diagnostic and treatment program (92004) provided on February 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for  dental services with an OON provider on 
July 25, 2023. 
 
You asked the Plan to waive the coinsurance for  dental services with an OON provider. You say that you 
didn't know the provider was out of network. 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 OON dental services.  
 
You have been asked to pay 20% coinsurance for dental services with an OON provider. This item/service falls 
within the OON dental 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 coinsurance for  
dental services with an OON provider on July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for  dentures provided on July 19, 2023. 
 
You asked the Plan to waive the coinsurance for  dentures . You say that you thought this would be covered in 
full. 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 50% 
coinsurance for prosthodontic services which includes dentures.  
 
You have been asked to pay 50% coinsurance for dentures. This item/service falls within the Dental 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 coinsurance for dentures provided on July 19, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement (D4355) provided on July 18, 2023. 
 
You asked the Plan to pay for full mouth debridement. You say that this should be covered. 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 full 
mouth debridement (D4355) provided on July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer onlay (D6110) and semi-precision attachment  
placement (D6192x3) provided on July 17, 2023. 
 
You asked the Plan to pay for retainer onlay and semi-precision attachment  placement. You say that this 
should be covered. 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 retainer 
onlay (D6110) and semi-precision attachment  placement (D6192x3) provided on July 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hearing aids (V5257) purchased on 
January 24, 2023. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 $800 
copayment for each classic level name-brand hearing aid.  
 
You have been asked to pay $1,600 ($800 copayment x 2) for the classic level hearing aids purchased in this 
case. 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 hearing aids (V5257) purchased on  
January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hot and cold test for checking the tooth (D0460) 
provided on August 28, 2023. 
 
You asked the Plan to reimburse for hot and cold test for checking the tooth (D0460). You say that every oral 
surgeon you called on the Plan list did not accept the dental Plan. The Plan denied your request. The Plan says 
this service is not covered in your dental benefit. The Plan also says the service must be part of your dental 
benefit for us to pay for it. 
 
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 reimburse for hot 
and cold test for checking the tooth (D0460) provided on August 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 1, 2023, to August 15, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this dentist worked with your asthma. 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 dental services provided on August 1, 2023, to August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve a consultation. You say that you are specialized for this patient's condition. 
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 the beneficiaries' 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 
a consultation to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 23, 2023, 
through July 24, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the documentation indicates that the emergency department (ED) evaluation on July 23, 
2023 demonstrated computed tomography (CT) evidence of a small subarachnoid hemorrhage and 
parenchymal hemorrhage. You were also intoxicated. The Glasgow Coma Scale was reported to be 13 in the 
field and 13 on presentation to the hospital. The History and Physical on July 23, 2023 noted plans to admit 
you for further observation. No repeat imaging was necessary. The next morning on July 24, 2023 your 
Glasgow Coma Scale was 15 and you were discharged home. The review has determined that the record did 
not show that at the time of the inpatient admission it was reasonable for the admitting physician to expect that 
your necessary hospital care (including earlier ED and/or observation care) would span two midnights with 
supporting documentation of your history and comorbidities, signs and symptoms, current medical needs, and 
risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from July 23, 2023, through July 24, 2023.