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

 
We decided that the Plan does not have to pay for ophthalmologist exam provided on February 22, 2023, by an 
out-of-network (OON) provider.  
 
 You asked the Plan to pay for ophthalmologist exam. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 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 ophthalmologist exam provided on February 22, 
2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 21, 2022, billed with 
codes 81314 & 81345 . 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 21, 2022, billed with codes 81314 & 81345 .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784), polarization (V272), and anti-
reflective coating (V2750) provided on March 18, 2023. 
 
You asked the Plan to pay for polycarbonate lenses (V2784), polarization (V272), and anti-reflective coating 
(V2750). You say that the representative told you that the glasses would be covered. The Plan denied your 
request. The Plan says these service codes are not a covered service. 
 
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 contact lenses, eyeglasses, single vision or lines multi-focal lens and 
frames. 
 
We looked at the file and the Plan's rules. The Plan rules state that they cover standard contact lenses, 
eyeglasses, single vision or lines multi-focal lens and frames. The Plan rules also state that enhancements 
including but not limited to the following are not covered through the allowance: anti-reflective, and 
polycarbonate lenses. Polarization is also not a covered benefit. Based on this information, we decided that the 
Plan's rules for coverage of polycarbonate lenses (V2784), polarization (V272), and anti-reflective coating 
(V2750) have not been met. Therefore, we decided that the Plan does not have to pay for polycarbonate lenses 
(V2784), polarization (V272), and anti-reflective coating (V2750) provided on March 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown - porcelain/ceramic (D2740), and post and 
core in addition to crown, indirectly fabricated (D2952) provided on January 4, 2023. 
 
You asked the Plan to pay more for the crown - porcelain/ceramic and post and core in addition to crown. You 
say that would like a review of the original decision regarding the payment you made for this claim as you feel 
it is unfair. 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 a crown - porcelain/ceramic (D2740), and 
post and core in addition to crown, indirectly fabricated (D2952) provided on January 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show that you can tolerate 3 hours of 
therapies per day. Services needed may be provided safely in a lower level of care. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
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 enrollee needs close monitoring 
while receiving up to six weeks of IV antibiotics. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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 eye and medical examination (92004) and assessment for 
prescription eye wear (92015) provided on February 28, 2023. 
 You asked the Plan to pay for eye and medical examination (92004) and assessment for prescription eye wear 
(92015). You say that these services are required to renew your driver's license. The Plan denied your request. 
The Plan says the services received are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for eye and medical examination (92004) and assessment for 
prescription eye wear (92015) provided on February 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's records 
do not show that your rehabilitation needs are complex. Services needed may be provided safely in a lower 
level of care. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital retinal imaging (S9986) provided on January 19, 
2023. 
 
You asked the Plan to pay for digital retinal imaging (S9986). You say that you do not agree with the denial for 
the eye examination. The Plan denied your request. The Plan says this service is not covered by the benefit 
contract. 
 
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 one routine non-medical eye examination per year through Plan providers. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one routine non-medical eye 
examination per year through Plan providers. The record shows that this is not a medically necessary service, 
which shows you agreed to pay out-of-pocket. Based on this information, we decided that the Plan's rules for 
coverage of digital retinal imaging have not been met. Therefore, we decided that the Plan does not have to pay 
for digital retinal imaging (S9986) provided on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22845 billed for date of service November 9, 
2022. 
 You asked the Plan to pay for procedure code 22845. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 22845 is bundled into payment for code 22853. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 22845 
is a column II code to column I code 22853. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 22845 billed for date of service November 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of implant body (D6100) and bone 
replacement graft for ridge preservation (D7953) provided on October 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that these procedures were needed because the 
implant got infected and was causing you pain. The Plan denied your request. The Plan says these services are 
not covered under the Plan's dental 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. 
 
 
  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 the 
surgical removal of implant body (D6100) and bone replacement graft for ridge preservation (D7953) provided 
on October 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for approval into an IRF. 
 
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 the enrollee has a history of an above the knee amputation and is living at home with 
frequent falls. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical 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 this enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral additional radiographic image (D0230) provided 
on March 14, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are asking to be reimbursed for the dental 
services. 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 the Plan paid for an intraoral radiographic image (D0220) on March 14, 2023; therefore, your benefit for 
the requested item or service was exhausted on the date of service of March 14, 2023. Therefore, we decided 
that the Plan does not have to pay for the intraoral additional radiographic image (D0230) provided on March 
14, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens provided on April 10, 2023. 
 
You asked the Plan to pay for the progressive lens. You say that you had cataract surgery, and a new 
prescription was required. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the progressive lens have not been met. Therefore, we decided that the Plan does not have to pay 
for the progressive lens provided on April 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on January 30, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete radiographic images (D0210), the 
panoramic image (D0330), and the 2D photographic images (D0350) provided on February 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that the benefits would be 
covered with the new provider, and you thought they would check to see if the x-rays would be covered. The 
Plan denied your request. The Plan says your benefit for the intraoral complete radiographic images and the 
panoramic image has already been exhausted. Also, the denial of payment for the 2D photographic images is 
correct because they are 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, certain limitations apply. The record 
shows the Plan paid for a panoramic image (D0330) on June 15, 2022; therefore, your benefit for the intraoral 
complete radiographic images (D0210) and the panoramic image (D0330) was exhausted on the date of service 
of June 15, 2022. The 2D photographic images are not covered under the Plans dental benefit. Therefore, we 
decided that the Plan does not have to pay for the intraoral complete radiographic images (D0210), the 
panoramic image (D0330), and the 2D photographic images (D0350) provided on February 7, 2023.  
 
Your complaint about being misled about your coverage by the provider and the Plan 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 the topical application of fluoride (D1204) provided on 
January 11, 2023. 
 
You asked the Plan to pay for the dental service. You say that the provider told you that they verified with an 
agent that fluoride would be covered. The Plan denied your request. The Plan says the denial of payment for 
topical application of fluoride is correct because the enrollee does not fit the age parameters; therefore, it 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 
covered under this benefit when you do not fit the age parameters. Therefore, we decided that the Plan does not 
have to pay for the topical application of fluoride (D1204) provided on January 11, 2023.
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 enrollee needs physical, occupational 
and speech therapy daily up to his capability, as he is currently a minimal to moderate assist and is alert and 
oriented, lived home independently prior to this admission, and is very motivated to work hard to get back 
home. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care 
and is currently unstable for transfer to an LTACH. 
 
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 there are no services available at the LTACH that the enrollee requires that are not available at the current health care setting being offered by the health plan. 
 
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.