Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the post and core in addition to crown, indirectly 
fabricated (D2952). 
 
You asked the Plan to pre-approve the post and core in addition to crown and endodontic therapy, molar tooth. 
You say that there is no other service that can be done for the tooth. The Plan denied your request. The Plan 
says this service is not covered in your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, post and core in addition to crown is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
the post and core in addition to crown, indirectly fabricated (D2952).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the bifocal lenses (V2200) provided on March 13, 2023. 
 
You asked the Plan to pay for the bifocal lenses. You say that you would like this bill to be waived. The Plan 
denied your request. The Plan says that this claim was processed in accordance with Plan benefits. 
 
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 provides an allowance of $300 every year to help pay for eyewear and contact lenses. 
 
We looked at the file and the Plan's rules. Specifically, the record only shows that the Plan paid $180 toward 
this purchase. You have a $300 benefit to be used each year. Write-offs and disallowed amounts are not 
benefits that are actually paid by the Plan. There is no documentation showing your $300 eyewear allowance 
had been exhausted prior to, or on this date of service. The allowed amount for the routine exam (92004) 
cannot be applied toward your eyewear allowance benefit. Based on this information, we decided that the 
Plan's rules for coverage of the bifocal lenses have been met. Therefore, we decided that the Plan has to pay for 
the remaining $72 for the bifocal lenses (V2200) provided on March 13, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dentures. The 
Plan denied your request. The Plan says the enrollee's 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the enrollee's benefit for the requested item or service was exhausted on the date of service of December 
5, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 06, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with 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 $50 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $50 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 a specialist office visit provided on December 06, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient hospital services provided on 
April 7, 2023. 
 
You asked the Plan to waive the cost share for outpatient hospital services. You say that you disagree with the 
cost share. 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 $525 deductible and a 10% coinsurance which applies to outpatient 
hospital services.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient hospital services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $525 
deductible and a 10% coinsurance which applies to outpatient hospital services. The total amount you are being 
asked to pay is $368.02 towards your $525 deductible. The total allowed amount for the outpatient hospital 
services is $26.89 ($26.89 x 10% = $2.69). This cost sharing is a contractual obligation that had not been met at the time outpatient hospital services was received on April 7, 2023. Therefore, we decided that the Plan does 
not have to waive the cost share for outpatient hospital services provided on April 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service November 
22, 2022. 
 
You asked the Plan to pay for procedure code 88305. You say that the report supports the services that were 
billed. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 1 for CPT code 88305. This means there is both a 
professional and technical component for the CPT code. In this case, an appropriate modifier to indicate the 
professional component has not been billed with CPT code 88305. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88305 billed for date of service November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the medical eye examination and the 
fundus photography or pay for the refraction provided on March 8, 2023. 
 
You asked the Plan to waive the copayments for the medical eye examination and the fundus photography and 
to pay for the refraction. You say that your annual notice of change showed that vision care exam went for a 
$35 copayment to a $0 copayment. You say you want to be refunded by your provider. 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 an in-network specialist's office and a $15 copayment for other in-network outpatient diagnostic 
testing.  
 
You have been asked to pay a $35 copayment for the medical eye examination and a $15 copayment for the 
fundus photography. The medical eye examination falls within the physician/practitioner services, including 
doctors office visits benefit category. The fundus photography falls within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category. The record shows a diagnosis of cataracts and benign 
neoplasm of the eye which makes the services medical in nature. 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 
copayments for the medical eye examination and the fundus provided on March 8, 2023. 
  
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 received during a routine eye examination. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was provided during a medical eye 
examination. Based on this information, we decided that the Plan's rules for coverage of the refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on March 8, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 20, 2023, to 
February 24, 2023, by an OON provider.  
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 home health services provided on February 20, 
2023, to February 24, 2023, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on March 31, 2023. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you should not have a copayment 
because this occurred during an office 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for outpatient diagnostic tests, including x-rays. 
 
You have been asked to pay a $20 copayment for the x-ray. This item/service falls within the outpatient 
diagnostic tests, including x-rays 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 records show you were not charged a copayment for the office visit, and 
were correctly charged a single copayment for the x-ray. Therefore, we decided that the Plan does not have to 
waive the copayment for the x-ray provided on March 31, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 as the enrollee's progress confirms she does not require intensive rehabilitation 
services. The enrollee is unable to weight bear on her left leg limiting her capacity to benefit from rehabilitation 
services pending healing of her surgical site. The enrollee does not require frequent physiatry oversight. 
 
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 an adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy 
procedures (D0431), topical application of fluoride varnish (D1206), and intraoral - periapical first 
radiographic image (D0220), provided on April 6, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0431, D1206, D0220, and D0274. You 
say that you are asking the Plan to review and reconsider payment. The Plan denied your request.  
The Plan says your benefit for the intraoral - periapical first radiographic image, has already been exhausted. 
The Plan also says that the adjunctive pre-diagnostic test and topical application of fluoride varnish are not 
listed as 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 adjunctive pre-diagnostic test and 
topical application of fluoride varnish are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for an adjunctive pre-diagnostic test that aids in detection of mucosal 
abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures 
(D0431), and topical application of fluoride varnish (D1206). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral - periapical first radiographic image (D0220) was exhausted on dates of 
service February 22, 2023, and April 6, 2022. The Plan agreed to approve code (D0274). Therefore, we decided 
that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) provided on 
April 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of artificial upper spine disc, anterior 
approach. 
 
You asked the Plan to pre-approve an outpatient surgery. You say that the enrollee is in a lot of pain and has 
tried conservative treatments. The Plan denied your request. The Plan says the two gel packets will not be 
placed next to each other. 
 
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 an outpatient surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the current request is not for two contiguous levels in the cervical spine. This is 
outside of the current FDA approval of artificial disc replacement. There is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted 
pathology. No compelling rationale is presented, or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested total disc arthroplasty at C3-4 and C5-6 
anterior approach is not medically reasonable or 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 outpatient surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an insertion of artificial upper spine disc, anterior approach.
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 the enrollee will benefit from services in an IRF.  
The Plan denied your request. The Plan says ongoing skilled care can be provided in an alternative setting.  
 
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. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested IRF admission is necessary because 
you are unable to walk without assistance and you are a fall risk. The Plan denied your request. The Plan says 
admission to an IRF is not medically necessary.  
 
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 that the complexity of your nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the you may have a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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. 
 
 
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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the knee brace provided by an in-network 
provider on November 27, 2022. 
 
You asked the Plan to waive the deductible for the knee brace. You say that the enrollee would like the cost to 
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. Your 
contract with the Plan says that there is a $750 deductible which applies to prosthetic devices and related 
supplies.  
 
You have been asked to pay a $445.76 deductible for the knee brace. The item or service you asked the Plan to 
waive the deductible for falls within the prosthetic devices 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 
prosthetic devices and related supplies. This cost sharing is a contractual obligation that had not been met at the 
time the knee brace was provided on November 27, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for the knee brace provided by an in-network provider on November 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 29, 2022, to 
October 24, 2022. You asked the Plan to pay for the home health services. You say that upon checking, our claim it was billed 
correctly. You also ask to please see the submitted files for review to prove the medical necessity 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 29, 2022. The NOA was not received by the Plan until July 30, 2022. 
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 provided on 
August 29, 2022, to October 24, 2022.