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

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514). 
 You asked the Plan to pre-approve kyphoplasty. 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 follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered when specific criteria are met. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no trial of fracture bracing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination and an eye scan 
provided on November 29, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination and an eye scan. You say that you 
have a routine once a year eye examination with a $0 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 $35 
copayment for all other Medicare-covered vision services. 
 
You have been asked to pay a $35 copayment for a medical eye examination and an eye scan. This item/service 
falls within the all other Medicare-covered vision 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 copayment for a medical eye examination and an eye scan provided on November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on March 
30, 2023. 
 
You asked the Plan to pay for the dental services. You say that your two x-rays were under different plans, so 
this x-ray 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 you received a covered complete series (D0210) on date of service October 7, 2019. Although these are 
two different services, they fall within the same category in your Evidence of Coverage and are subject to the 
same frequency limitations. Therefore, this benefit has been exhausted as of March 30, 2023. Therefore, we 
decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on March 30, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025), progressive lenses (V2781), and a 
deluxe lens feature (V2702) provided March 9, 2023. 
 
You asked the Plan to pay for deluxe frames (V2025), progressive lenses (V2781), and a deluxe lens feature 
(V2702). You say that the Plan has only one provider where you live. You also say this provider is of 
questionable repute. The Plan denied your request. The Plan says the benefit plan does not cover this out-of-
network vision care service/material. 
 
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 they are obtained from an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $100 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). The Plan rules also say they 
do not cover any benefits received at a non-network optical provider. The record shows services were received 
from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of 
deluxe frames (V2025), progressive lenses (V2781), and a deluxe lens feature (V2702) have not been met. 
Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025), progressive lenses 
(V2781), and a deluxe lens feature (V2702) provided March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alveoloplasty in conjunction with extractions(D7310), 
extraction, erupted tooth (D7210, D7140), and drugs or medicaments dispensed in the office for home use 
(D9630) provided on February 21, 2023. 
 
You asked the Plan to pay for alveoloplasty, extractions and drugs or medicaments dispensed in the office for 
home use. 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 
alveoloplasty in conjunction with extractions(D7310), extraction, erupted tooth (D7210, D7140), and drugs or 
medicaments dispensed in the office for home use (D9630) provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
provided on May 04, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014). You say that you are 
appealing with supporting records. 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 Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of 
the eye.  
You have been asked to pay a $45 copayment for a medical eye examination (92014). This item/service falls 
within the Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the 
eye 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 medical eye examination 
(92014) provided on May 04, 2023.
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 you are appealing this denial. 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health visit provided on April 6, 2023, by an OON 
provider.  
 
You asked the Plan to pay for home health visit. 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 visit provided on April 6, 2023, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on April 14, 2023. 
 
You asked the Plan to pay for the dental service. You say that it was a medically emergency that you a 
specialist to try and save your tooth. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the consultation is not covered by the Plan. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) and intraoral - complete series of radiographic images (D0210) provided on March 6, 2023. 
 
You asked the Plan to pay for the comprehensive oral evaluation and intraoral - complete series of radiographic 
images. 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 January 26, 2023.  Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided on March 
6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that this is medically necessary. 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 May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for dental care. 
 
You asked the Plan to pre-approve anesthesia for dental care. 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 pre-approve 
anesthesia for dental care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the requested testing. You say that the testing will determine long-term 
medical management. The Plan denied your request. The Plan says the testing is not clinically efficacious. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The requested testing is not considered medically necessary. Based 
on this information, we decided that Medicare rules for coverage of the requested testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you feel like your foot is trapped in your shoe. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
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 pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant/ porcelain tooth #19 (D6066) and prefabricated 
implant abutment tooth #19 (D6056) provided on March 6, 2023. 
 
You asked the Plan to pay for an implant and a prefabricated implant abutment. 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 implant/ 
porcelain tooth #19 (D6066) and prefabricated implant abutment tooth #19 (D6056) provided on March 6, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rechargeable hearing aids provided on February 10, 2023. 
 
You asked the Plan to pay for rechargeable hearing aids. You say that you were not aware that the chosen 
hearing aids were not part of the program. The Plan denied your request. The Plan says this particular hearing 
aid is not on the list of approved items/devices. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
specific hearing aids that are listed in the EOC.  
 
We looked at the file and the Plan's rules. The documentation provided shows that a representative with 
Hearing Care Solutions reviewed the copayment structure with you for covered devices and that you chose to 
order a pair of hearing aids not on the formulary. Based on this information, we decided that the Plan's rules for 
coverage of rechargeable hearing aids have not been met. Therefore, we decided that the Plan does not have to 
pay for rechargeable hearing aids provided on February 10, 2023.  
 Your complaint about the participating provider not explaining coverage well 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on February 07, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that there is no 
copayment for an x-ray or MRI and you feel you should not have had the MRI on your back at all. 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 $200 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $200 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic tests 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 $195.98, which is less than the standard copayment for an 
MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
image (MRI) provided on February 07, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate arterial embolization (37243). 
 
You asked the Plan to pre-approve prostate arterial embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 prostate arterial embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found prostatic arterial embolization (PAE) is not medically reasonable and 
necessary in this case. PAE is considered an experimental technique to treat symptomatic benign prostatic 
hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. The most recent AUA guidelines do not recommend this procedure outside of a clinical trial setting due to the 
heterogeneity in the available literature and safety concerns regarding radiation exposure, postembolization 
syndrome, vascular access, technical feasibility, higher clinical failure rate compared with more traditional 
methods. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate arterial embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate arterial embolization (37243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7210 x1), bone replacement grafts 
(D7953 x4) and deep sedation (D9222, D9223). 
 
You asked the Plan to pre-approve extractions (D7210 x4), bone replacement grafts (D7953 x4) and deep 
sedation (D9222, D9223). You say that this doesn't make sense because you believed you were already 
approved for this surgery back in May and only requested an extension. You say you are requesting this appeal 
be expedited because you have been trying since December to get this surgery. The Plan denied your request. 

The Plan says only dental codes listed will be covered. The Plan also says your benefit offers coverage for one 
dental extraction per year when rendered by a participating general dentist or oral surgeon. The Plan has 
approved three dental extractions. Although the benefit is limited to one extraction, you were approved for two 
more as a one-time exception. This was due to an error on the Plan's part, and therefore the Plan will still honor 
that approval. 
 
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 your benefit for extractions was exhausted on August 14, 2023 when the Plan approved coverage for 
three of the requested extractions. Bone replacement grafts (D7953) and deep sedation (D9222, D9223) are not 
among the procedures covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve an extraction (D7210 x1), bone replacement grafts (D7953 x4) and deep sedation (D9222, D9223).