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

 
We decided that the Plan does not have to pay for the ultrasound of head and neck provided on March 30, 
2023, to June 03, 2023. 
 
You asked the Plan to pay for the ultrasound of head and neck. 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 ultrasound of head 
and neck provided on March 30, 2023, to June 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 24, 2023. 
 
You asked the Plan to pay for office visit. You say that you were not aware of the need for prior authorization. 
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 office visit provided on 
February 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a finger x-ray provided on March 11, 2023. 
 
You asked the Plan to pay for a finger x-ray. You say that this was medically necessary, please review the 
records to reconsider coverage. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a finger x-ray provided 
on March 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 24, 2023. 
 
You asked the Plan to pay for an office visit. You say that the office advised you on which provider you should 
see, per your Plan. You trusted them and still got this denial. 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 an office visit provided 
on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 01, 2023, to February 25, 
2023. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for the service 
provided. 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 office visit provided on 
February 01, 2023, to February 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit evaluation provided on April 12, 2023. 
 
You asked the Plan to pay for a home visit evaluation. 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 a home visit evaluation 
provided on April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each infusion therapy service provided on 
April 12, 2023, to April 21, 2023. 
 
You asked the Plan to waive the copayment for each infusion therapy service. You say that the enrollee was 
unaware of a copayment associated with these services. 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 $295 
copayment for each in-network outpatient hospital facility visit. 
 
You have been asked to pay a $295 copayment for each infusion therapy service. This item/service falls within 
the each in-network outpatient hospital facility visit 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 the enrollee owes is $590 ($295 copayment x 2 services 
= $590). Therefore, we decided that the Plan does not have to waive the copayment for each infusion therapy 
service provided on April 12, 2023, to April 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for EKG provided on April 25, 2023. 
 
You asked the Plan to waive the copayment for EKG. You say that you feel that this copayment is not 
applicable because you already paid for the 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 $30 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $30 copayment for EKG. 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 EKG provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 06, 
2023. 
 
You asked the Plan to pay for the subsequent 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 subsequent nursing 
facility care provided on January 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan, an injection procedure, and a renal tube 
removal procedure to be provided by an out-of-network OON provider.  
 
You asked the Plan to pre-approve a CT scan, an injection procedure, and a renal tube removal procedure. You 
say that you are requesting reconsideration of the denied service. The Plan denied your request. The Plan says 
this service was not approved. 
 
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 CT scan, an injection procedure, and a renal tube removal procedure to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), trifocal, spherocylinder lenses (V2303), and 
anti-reflective coating (V2750) provided on May 9, 2023.  
You asked the Plan to pay for frames (V2020), trifocal, spherocylinder lenses (V2303), and anti-reflective 
coating (V2750). You say that the denial was based on the belief that your optical allowance has been 
exhausted, which is incorrect. You also say your May purchase of new glasses was the first time you had used 
your $300 eyewear benefit in 2023. 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 allowance you can use to pay for eyewear to correct vision. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan provides a $300 allowance every 
calendar year that you can use to pay for eyewear to correct vision. The record shows the benefit was exhausted 
with this date of service. Based on this information, we decided that the Plan's rules for coverage of frames 
(V2020), trifocal, spherocylinder lenses (V2303), and anti-reflective coating (V2750) have not been met. 
Therefore, we decided that the Plan does not have to pay for frames (V2020), trifocal, spherocylinder lenses 
(V2303), and anti-reflective coating (V2750) provided on May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781), a miscellaneous vision item or 
service (V2799), and anti-reflective coating (V2750) provided on April 6, 2023. 
 
You asked the Plan to pay for progressive lenses (V2781), a miscellaneous vision item or service (V2799), and 
anti-reflective coating (V2750). You say that before buying glasses, you checked four in-network providers, 
and found them to be $700 to $1,000. You also say this was unaffordable for your budget. The Plan denied 
your request. The Plan says your mandatory supplemental vision plan only covers in network providers. 
 
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 you receive services through a vision benefit optical 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 or contact lenses at a network optical provider. The Plan rules also 
say that any benefits received at a non-network optical provider are excluded from the vision benefit. Based on 
this information, we decided that the Plan's rules for coverage of progressive lenses (V2781), a miscellaneous 
vision item or service (V2799), and anti-reflective coating (V2750) have not been met. Therefore, we decided 
that the Plan does not have to pay for progressive lenses (V2781), a miscellaneous vision item or service 
(V2799), and anti-reflective coating (V2750) provided on April 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 x4) provided on 
April 5, 2023, to April 14, 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 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 February 3, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 x4) 
provided on April 5, 2023, to April 14, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, conventional air services and air mileage provided 
on October 4, 2022. 
 
You asked the Plan to pay for the ambulance air services and air mileage. You say that due to the enrollee's 
condition any other form of transportation would be medically contraindicated.  The Plan denied your request. 
The Plan says that after reassessing the entire clinical situation, information provided at the time of the appeal 
does not support criteria for air ambulance transport.  
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 the ambulance air services and air mileage. 
Our reviewer says that the ambulance air services were medically necessary. Our physician reviewer found 'the 
enrollee with chest pain and Non-ST-elevation myocardial infarction was transported via ambulance to another 
hospital for a higher level of care and definitive treatment. This mode of transport was medically necessary and 
the alternate mode of transportation would have taken more than 12 hours which could have further 
compromised the health of 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 the ambulance air services and air mileage have been met. Therefore, we 
decided that the Plan has to pay for ambulance service, conventional air services and air mileage provided on 
October 4, 2022.  
 
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 a limited oral evaluation (D0140) provided on December 29, 
2021. 
 
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 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 19, 2021. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 29, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership (S9970) 
purchased on April 26, 2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not payable as you 
have not provided valid proof of payment.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
  
 
 
 
The Plans rules for coverage of gym benefits have not been met because you have not provided valid proof of 
payment for the health club membership purchased in this case. Specifically, the payment information provided 
for this membership does not indicate your name on the documentation. Therefore, we decided that the Plan 
does not have to issue reimbursement for the health club membership (S9970) purchased on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), 
bitewings - four radiographic images (D0274), and periodontal maintenance (D4910) provided on January 14, 
2022. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewings and periodontal maintenance. You say 
that no one told you that there was a time limit to submit a reimbursement. The Plan denied your request. The 
Plan says the claim was untimely, and the submission did not meet the exception criteria 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 periodic oral evaluation, bitewings and periodontal maintenance was not 
filed until March 16, 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 periodic oral evaluation 
- established patient (D0120), bitewings - four radiographic images (D0274), and periodontal maintenance 
(D4910) provided on January 14, 2022.  
 Your complaint about the Plans representatives is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on March 14, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for home visit. You say that you are requesting reconsideration stating the claim was 
denied due to no authorization. The Plan denied your request. The Plan says Medicare rules say that health 
Plans can require enrollees to get care from network providers. 
 
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 visit provided on March 14, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that the enrollee has had two medial 
branch blocks already. The Plan denied your request. The Plan says that the radiofrequency ablation is not 
medically necessary.  
 
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 the radiofrequency ablation. Our 
reviewer says that the enrollee does meet the LCD coverage criteria. Our physician reviewer found that the 
enrollee has had 50% pain relief for a year after the initial radiofrequency ablation procedure. Therefore , the 
request to repeat the radiofrequency ablation is medically reasonable 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 the radiofrequency ablation have been met. Therefore, we decided that the Plan 
has to pre-approve the radiofrequency ablation.  
 
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.