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

 
We decided that the Plan does not have to pay more for dental services provided by an out-of-network provider 
on July 18, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with these charges. 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.  
 
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. 
 
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 dental services provided by an out-of-
network provider on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye injection (67515) and a triamcinolone injection 
(J3301) provided on June 02, 2023. 
 
You asked the Plan to pay for an eye injection (67515) and a triamcinolone injection (J3301). You say that you 
are appealing and have submitted documents that support the medical necessity of this service. 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 eye injection (67515) 
and a triamcinolone injection (J3301) provided on June 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on August 23, 2023. 
 
You asked the Plan to pay for hearing aids. You say that you contact at least 10 of the providers approved by 
the Plan. You also say that no one specialized in tinnitus, but they did address it as part of their services. The 
Plan denied your request. The Plan says the hearing benefit is not covered if the services are not registered in 
advance. The Plan also says that hearing aids ordered through providers other than the Plan hearing are not 
covered. 
 
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 
hearing aids only when you obtain the hearing aids through a Plan hearing network provider.  
 
 
  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids provided on August 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine foot care services provided on August 07, 2023. 
 
You asked the Plan to pay for routine foot care 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 routine foot care 
services provided on August 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 25, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the enrollee has veteran status. Therefore, Medicare does 
not cover services for Veteran Affairs hospitals, medical centers or administration hospitals. 
 
The Plan must follow Medicare rules. The rules say that VA facilities and military hospitals are excluded from 
participating in Medicare. The rules also say that Medicare payment cannot be made to a provider that is not 
enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an office visit provided on April 25, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management of an established patient 
provided on December 28, 2021. 
 
You asked the Plan to pay for evaluation and management of an established patient. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says if you see a 
provider that has opted out of Medicare, you will be responsible for the entire charge except in urgent or 
emergency situations. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for evaluation 
and management of an established patient provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 20, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 15, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic diagnostic imaging provided on July 25, 2023. 
 
You asked the Plan to pay for ophthalmic diagnostic imaging. 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 ophthalmic diagnostic 
imaging provided on July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye examination provided on August 4, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the eye examination. You say that your office sees multiple patients with many 
different types of Aetna plans. You say the card does not state that referrals are required. You say if the 
enrollee was required to obtain a referral, they would know prior to any visit so they would be sure to see a 
network provider. The Plan denied your request. The Plan says services from nurse practitioners are not 
covered unless preauthorized. 
 
 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 did not pre-approve the 
eye examination. We found no exception that would require the Plan to pay for the eye examination. Therefore, 
we decided that the Plan does not have to pay for the eye examination provided on August 4, 2023, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a specialist office visit (99213) and fundus photography (92250) 
provided on July 27, 2023. 
 
You asked the Plan to pay for a specialist office visit (99213) and fundus photography (92250). You say that 
you did not know you need to check with the Plan. You also say you thought your optometrist referred you so 
you could make an appointment to see the specialist. The Plan denied your request. The Plan says that this is 
not a covered by the vision Plan. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for a specialist office visit (99213) and fundus photography (92250) by a contract provider. 
The file does not show that the Plan provided notice that a specialist office visit (99213) and fundus 
photography (92250) would not be covered. Under Medicare rules, this means a specialist office visit (99213) 
and fundus photography (92250) is considered approved by the Plan. Therefore, we decided that the Plan has to 
pay for a specialist office visit (99213) and fundus photography (92250) provided on July 27, 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 pay for frames (V2020), lenses (V2100), anti-reflective coating 
(V2750), and polycarbonate lenses (V2784) provided on April 27, 2023. 
 
You asked the Plan to pay for frames (V2020), lenses (V2100), anti-reflective coating (V2750), and 
polycarbonate lenses (V2784). You say that the enrollee has been diagnosed with dry age-related macular 
disease over the past five years and has suffered an increasing rate loss of vision during this time. You also say 
this vision loss has required the enroll to frequently change her prescriptions and obtain pairs of glasses at her 
own expense to maintain limited activity and quality of life. The Plan denied your request. The Plan says the 
services are covered benefits, but the enrollee has exceeded limits set in the subscriber agreement. 
 
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 once every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say that this service is covered once every two years. 
The record shows this benefit was exhausted on February 16, 2022. Based on this information, we decided that 
the Plan's rules for coverage of frames (V2020), lenses (V2100), anti-reflective coating (V2750), and 
polycarbonate lenses (V2784) have not been met. Therefore, we decided that the Plan does not have to pay for 
frames (V2020), lenses (V2100), anti-reflective coating (V2750), and polycarbonate lenses (V2784) provided 
on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on September 2, 2022. 
 
You asked the Plan to pay for acupuncture services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the requested for acupuncture and therapy services 
provided by a licensed acupuncturist for a diagnosis of low back pain is not approved. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the requested services must be under the appropriate 
level of supervision of a physician, physician assistant (PA), or nurse practitioner (NP)/clinical nurse specialist 
(CNS). Therefore, we decided that the Plan does not have to pay for acupuncture services provided on 
September 2, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
January 5, 2023. 
 
You asked the Plan to pay for the ED services. You say that you have attached the documentation so the claim 
can be reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be 
made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on January 5, 
2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says the records do not show a failed trial of Bevacizumab. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that Eylea is 
not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drugs, or 
any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete mandibular denture (D5120) provided on June 
30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 November 9, 2020. 
Therefore, we decided that the Plan does not have to pay for a complete mandibular denture (D5120) provided 
on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement grafts (D4263 and D4264) provided on 
December 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were medically necessary 
due to a medical condition and were necessary prior to the implant. The Plan denied your request. The Plan 
says the denial of payment for these services is correct, because the bone replacement grafts are not covered by 
Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the bone replacement grafts 
(D4263 and D4264) provided on December 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office services provided on June 15, 2022. 
 
You asked the Plan to pay for office services. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the claim must be filed no later than the close of the period 
ending 1 calendar year after the date of service. 
 
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 office services was not filed until July 6, 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 office services provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on 
August 7, 2023.  
You asked the Plan to pay for a determination of refractive state (92015). You say that the service provided by 
this provider was related to the operation and not a routine refractory check. The Plan denied your request. The 
Plan says this service was not paid because it's not covered by Medicare. 
 
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 does not cover routine eye examinations (eye refractions) for eyeglasses/contacts. 
 
We looked at the file and the Plan's rules. The Plan rules say eye refractions are not covered by Original 
Medicare. Based on this information, we decided that the Plan's rules for coverage of a determination of 
refractive state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for a 
determination of refractive state (92015) provided on August 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 18, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses and deluxe frames provided on June 16, 
2023. 
 
You asked the Plan to pay for progressive lenses and deluxe frames. You say that the one in-network provider 
that is in your area is of questionable repute and has some of the most expensive glasses. The Plan denied your 
request. The Plan says the claim is from a provider who is not in your network. 
 
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 obtain your eyewear from a Plan vision network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that any benefits received at a non-network optical 
provider are excluded from coverage. Based on this information, we decided that the Plan's rules for coverage 
of progressive lenses and deluxe frames have not been met. Therefore, we decided that the Plan does not have 
to pay for progressive lenses and deluxe frames provided on June 16, 2023.