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

 
We decided that the Plan does not have to pay for a nursing facility visit provided on December 12, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that you depend on the facility staff to verify 
eligibility and to obtain 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 a nursing facility visit 
provided on December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 01, 2023. 
 
You asked the Plan to pay for lab services. You say that the enrollee was in a nursing home at the time that the 
services were rendered. 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 lab services provided on 
February 01, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mammography provided on October 19, 2022. 
 
You asked the Plan to pay for mammography. You say that you are requesting reconsideration for the services 
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 mammography provided 
on October 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting. 
Documentation does not support that LTACH services are medically appropriate at this time. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and the lenses provided on March 21, 2023. 
 You asked the Plan to pay for the frames and the lenses. You say that you would like to be reimbursed for the 
services. You say that there were no indicators in the document stating the limitations for the services. The Plan 
denied your request. The Plan says the services were not covered 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 covers these services when received by an in-network provider. 
 
We looked at the file and the Plan's rules. Specifically, the items were provided by an out-of-network provider. 
Based on this information, we decided that the Plan's rules for coverage of the frames and the lenses have not 
been met. Therefore, we decided that the Plan does not have to pay for the frames and the lenses provided on 
March 21, 2023.  
 
Your complaint about that the Plan is misleading 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a guided tissue regeneration (D7956) provided on February 
6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for all of these 
services. The Plan denied your request. The Plan says your annual dental allowance amount 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 annual dental allowance amount of $1,500 was exhausted on date of service February 6, 2023. Therefore, we decided that the Plan does not have to pay for a guided tissue regeneration (D7956) provided on 
February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025), sphere lenses (V2100) and anti-
reflective coating (V2750) provided on March 1, 2023. 
 
You asked the Plan to pay for deluxe frames (V2025), sphere lenses (V2100) and anti-reflective coating 
(V2750). You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
the $200 allowance listed in the EOC is applied to the full retail price. The Plan also says that this claimed are 
processed correctly and will be upheld. 
 
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 $200 benefit toward the purchase and fitting and eyeglasses and pair of lenses or 
contact lenses (1 per calendar year). 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover $200 benefit toward the purchase 
and fitting and eyeglasses and pair of lenses or contact lenses (1 per calendar year). The Plan rules also say that 
you pay any amount of the $200 retail price. Based on this information, we decided that the Plan's rules for 
coverage of deluxe frames (V2025), sphere lenses (V2100) and anti-reflective coating (V2750) have not been 
met. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025), sphere lenses 
(V2100) and anti-reflective coating (V2750) provided on March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodontal scaling and root planing (D4341) provided 
on February 2, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you believe that the Plan should cover 
more. 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 periodontal scaling and root planing (D4341) 
provided on February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic diagnostic imaging (92134) and a medical eye 
examination (92014) provided on March 01, 2023. 
 
You asked the Plan to pay for ophthalmic diagnostic imaging (92134) and a medical eye examination (92014). 
You say that they are a contracted provider with the Plan. 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 (92134) and a medical eye examination (92014) provided on March 01, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Keytruda (pembrolizumab) provided on March 2, 2023. 
 
You asked the Plan to pay for the medication. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says that the medication is considered experimental or investigational for 
the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pay for the medication. Our reviewer says that the 
medication is medically reasonable and necessary. Our physician reviewer found the medication is approved 
for stage 4 non-small-cell lung cancer (NSCLC) patients with >1% PD-L1 without chemotherapy. 
 
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 medication have been met. Therefore, we decided that the Plan has to pay 
for Keytruda (pembrolizumab) provided on March 2, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2 sensor.  
You asked the Plan to pre-approve the FreeStyle Libre 2 sensor. The Plan denied your request. The Plan says 
criteria for the CGM has not been met.  
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre 2 sensor. Our 
reviewer says that the FreeStyle Libre 2 sensor is not medically necessary. Our physician reviewer found 
coverage criteria require either low blood glucose sugar and insulin use for CGM coverage. You are not having 
low blood glucose sugar and are not taking insulin. Although the CGM might be helpful criteria for CGM 
coverage are not met at this time. 
 
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 FreeStyle Libre 2 sensor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve FreeStyle Libre 2 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extracapsular cataract removal (66984), occupational 
multifocal lens (V2786) and presbyopia-correct function (V2788) provided from February 2, 2021, to February 
23, 2021. 
 
You asked the Plan to pay for extracapsular cataract removal (66984), occupational multifocal lens (V2786) 
and presbyopia-correct function (V2788). You say that the surgery coordinator told you that they do not take 
your insurance. You also say that you were looking in the Plan directory and saw the clinic listed as covered, so 
you decided to call. The Plan denied your request. The Plan says you must submit your claim to them within 12 
months of the date you received the service or item. 
 
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 extracapsular cataract removal (66984), occupational multifocal lens 
(V2786) and presbyopia-correct function (V2788) was not filed until January 31, 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 extracapsular cataract removal (66984), occupational multifocal lens (V2786) 
and presbyopia-correct function (V2788) provided from February 2, 2021, to February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on March 29, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you received no medical 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 $35 
copayment for in-network Medicare-covered services received from a specialist or specialists office. 
 
You have been asked to pay a $35 copayment for an office visit. This item/service falls within the in-network 
Medicare-covered services received from a specialist or specialists office 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 an office visit provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) provided on April 12, 
2023. 
 
You asked the Plan to pay for a medical eye examination (92014). You say that you get one eye examination 
per year. You also say you want this paid to you because you had to pay this. 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 medical eye 
examination (92014) provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 16, 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 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 February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 0079U and G0483 provided on January 3, 
2023. 
 
You asked the Plan to pay for procedure codes 0079U and G0483. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing (0079U) did not include the required unique identifier. Additionally, the records did not 
include laboratory results for procedure code G0483. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. Medicare rules also say that the provider, 
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to 
determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported for procedure code 0079U. Additionally, the records provided for review did not include 
laboratory results in order to verify the billing of code G0483. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 0079U and G0483 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 0079U and G0483 provided on January 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on February 03, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment 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 home visit provided on 
February 03, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor.  
You asked the Plan to pre-approve the Freestyle Libre 2 sensor. You say that you have been using these for 
years and they have always been covered. You also say that you believe the denial is due to having a different 
insurance plan. The Plan denied your request. The Plan says you are not on insulin and you have no 
documented hypoglycemic episodes. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin or have a 
history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for coverage 
of the Freestyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network injection provided on 
March 1, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network injection. You say that you are having these 
injections monthly and cannot afford these high costs. 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% 
coinsurance for Medicare Part B prescription drugs.  
 
The allowed amount of this drug is $2,070.09, resulting in a coinsurance amount of $414.02 ($2,070.09 x 20% 
= $414.02). You have been asked to pay a $414.02 coinsurance for an in-network injection. This item/service falls within 
the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for an in-network injection provided on March 1, 2023.