Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on July 6, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you were unaware that there was a $2,500 
limit on coverage when out of state. The Plan denied your request. The Plan says that based on your claims 
history, you have met the $2,500 limit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the records do not show that you have met the maximum 
Convenience Care benefit of $2,500 for the 2023 plan year. This means that the Plan has not provided a valid 
reason for denying payment of the services. It is the burden of the Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated. Additionally, Medicare covers out of area care in 
certain scenarios, which means the Plan also covers out of area care if Medicare criteria are met. In this case, 
the Plan has not provided any evidence that medical records were requested and reviewed to determine if out of 
area Medicare criteria were met. Therefore, we decided that the Plan has to pay for the laboratory services 
provided on July 6, 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 a pneumatic compressor (E0652) and segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667 x2). 
 
You asked the Plan to pre-approve a pneumatic compressor and full leg segmental pneumatic appliances. 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 a segmented, calibrated gradient PCD (E0652) is only 
covered when the individual has unique characteristics which prevent them from receiving adequate 
satisfactory pneumatic compression treatment using a nonsegmented device along with a segmented appliance 
or compression device without manual control of the pressure in each chamber. 
 
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 a pneumatic compressor and full leg 
segmental pneumatic appliances. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the documentation does not support that the enrollee has failed at least 4 weeks of 
conservative care with a basic lymphedema pump. Additionally, the documentation does not support that the 
enrollee has physical findings consisting of truncal, abdominal or chest edema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a pneumatic compressor and full leg segmental pneumatic appliances have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) 
and segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667 x2).
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 requested LTACH care is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested LTACH care is not 
considered medically reasonable and necessary in this case. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short-term acute 
care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee 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 dental services provided on July 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was 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 July 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950 x2), gingivectomy or gingivoplasty 
(D4212), resin-based composite - one surface, posterior (D2391) and a crown - porcelain/ceramic (D2740) 
provided on July 27, 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 $1,000 annual maximum 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 $1,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay for core buildup (D2950 x2), gingivectomy or gingivoplasty (D4212), resin-based composite - one surface, 
posterior (D2391) and a crown - porcelain/ceramic (D2740) provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve block provided on September 6, 2023. 
 
You asked the Plan to pay for a genicular nerve block. You say that the procedure performed was medically 
necessary. The Plan denied your request. The Plan says this service does not meet this requirement of the 
enrollee's Plan of benefits and is excluded from coverage. 
 
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 pay for a genicular nerve block. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a genicular nerve block is experimental for knee pain and requires more research. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pay for a genicular nerve block provided on September 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine ophthalmological examination including refraction 
(S0620), progressive lenses (V2781), polycarbonate lenses (V2784) and miscellaneous vision item or service 
(V2799) provided on June 5, 2023.     
 
You asked the Plan to pay for routine ophthalmological examination including refraction, progressive lenses, 
polycarbonate lenses, and miscellaneous vision item or service. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says eye examinations and eyewear must be obtained from a 
provider in the Plan's vision vendor network. The Plan also says that services obtained from vendors outside 
this network are not covered. 
 
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 the vision services are obtained from an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that vision services obtained from vendors outside 
this network are not covered. Based on this information, we decided that the Plan's rules for coverage of routine 
ophthalmological examination including refraction, progressive lenses, polycarbonate lenses, and 
miscellaneous vision item or service have not been met. Therefore, we decided that the Plan does not have to 
pay for routine ophthalmological examination including refraction (S0620), progressive lenses (V2781), 
polycarbonate lenses (V2784) and miscellaneous vision item or service (V2799) provided on June 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device. 
 
You asked the Plan to pre-approve the Vertiflex Superion interspinous device. You say that the enrollee has 
significant pain, and it is impacting their quality of life. The Plan denied your request. The Plan says the 
medical necessity of this treatment has not been established. 
 
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 the Vertiflex Superion interspinous 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Vertiflex device is experimental. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex Superion interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230), intraoral - periapical first radiographic image (D0220) and adjunctive pre-diagnostic test that aids in 
detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or 
biopsy procedures (D0431) provided on August 9, 2023, to August 11, 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 intraoral - periapical each additional radiographic image and the 
intraoral - periapical first radiographic image 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 August 9, 2023, to 
August 11, 2023. Therefore, we decided that the Plan does not have to pay for intraoral - periapical each 
additional radiographic image (D0230), intraoral - periapical first radiographic image (D0220) and adjunctive 
pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant 
lesions, not to include cytology or biopsy procedures (D0431) provided on August 9, 2023, to August 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 24, 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 $2,000 annual maximum 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 $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 01, 2022. 
 
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 November 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fitness equipment provided on June 1, 2023. 
 
You asked the Plan to pre-approve the fitness equipment. You say that you want to be reimbursed for the 
fitness equipment. The Plan denied your request. The Plan says the service criteria was not met. 
 
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 Plan covers gym benefits 
only the Wellness Allowance reimbursement form is submitted along with proof of payment and any additional 
information outlined on the form. 
 
The Plans rules for coverage of gym benefits have not been met because the request for reimbursement and the 
proof of payment do not match your name as it appears in the Plan's records. Therefore, we decided that the 
Plan does not have to pre-approve the fitness equipment provided on June 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab testing provided on March 29, 2023. 
 
You asked the Plan to waive the copayment for the lab testing. You say that you want to appeal the amount 
being charged. 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 $15 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $15 copayment for the lab testing. 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 the lab testing provided on March 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services provided on April 24, 2023. 
 
You asked the Plan to pay for portable x-ray services. You say that there was no time 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 portable x-ray services 
provided on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lens, index 1.54-1.65 Plast or 1.60-1.79 green lens slide 
(GLS) (V2782), progressive lenses (V2781), ultraviolet (U-V) lenses (V2755), anti-reflective coating (V2750) 
and photochromatic tint (V2744) provided on June 30, 2023. 
 
You asked the Plan to pay for lens, index 1.54-1.65 Plast or 1.60-1.79 GLS, progressive lenses, U-V lenses, 
anti-reflective coating and photochromatic tint. You say that you had surgery on August 19, 2019, and were 
told that your eyes are still healing. You also say that the change in prescription is necessary as your eyes are 
still healing. The Plan denied your request. The Plan says these services are not covered under this benefit. 
 
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 standard lenses only. 
 
We looked at the file and the Plan's rules. The Plan rules say that lens enhancements are not covered under your 
benefit. Based on this information, we decided that the Plan's rules for coverage of lens, index 1.54-1.65 Plast 
or 1.60-1.79 GLS, progressive lenses, U-V lenses, anti-reflective coating and photochromatic tint have not been 
met. Therefore, we decided that the Plan does not have to pay for lens, index 1.54-1.65 Plast or 1.60-1.79 green 
lens slide (GLS) (V2782), progressive lenses (V2781), ultraviolet (U-V) lenses (V2755), anti-reflective coating 
(V2750) and photochromatic tint (V2744) provided on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids provided on September 12, 2023. 
 
You asked the Plan to reimburse for hearing aids. You say that you went to the Plan hearing vendor 
recommended and they shipped your hearing aids to the other side of the country. You also say you became 
frustrated, went to this vendor, and were able to get the exact same ones, so you cancelled the other ones. The 
Plan denied your request. The Plan says you did not purchase the hearing aids from a Plan specific hearing 
provider as instructed in your EOC.  
 
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 go 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 reimburse for 
hearing aids provided on September 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable ankle x-rays provided on May 31, 2023. 
 
You asked the Plan to pay for portable ankle x-rays. You say that there was no time 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 portable ankle x-rays 
provided on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultraviolet (UV) phototherapy wand (E0691) provided on 
August 10, 2023. 
 
You asked the Plan to pay for the UV phototherapy wand. You say that this item was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that ultraviolet light systems are covered for selected 
patients with generalized intractable psoriasis. 
 
We looked at the file and Medicare rules. The records show no diagnosis of psoriasis. Based on this 
information, we decided that Medicare rules for coverage of the UV phototherapy wand have not been met. 
Therefore, we decided that the Plan does not have to pay for an ultraviolet (UV) phototherapy wand (E0691) 
provided on August 10, 2023.