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

 
We decided that the Plan does not have to waive the copayment for the medical examination and evaluation 
(92012) provided on June 29, 2023. 
 
You asked the Plan to waive the copayment for the eye exam. You say that this was a follow up visit and there 
should be no copayment. The Plan denied your request. The Plan says the cost sharing will be applied 
according to the Plan contract. 
 
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 $50 
copayment for a specialist's office visit for vision care.  
 
 
  You have been asked to pay a $50 copayment for a specialist's office visit for the eye exam. This item/service 
falls within the vision care 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 medical 
examination and evaluation (92012) provided on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750). 
 
You asked the Plan to pre-approve the crown. You say that the language in the EOC and Annual Notice of 
Change (ANOC) shows theres comprehensive coverage, but you still received a denial of coverage and you 
might not get the 2024 plan because of it. The Plan denied your request. The Plan says this is not a covered 
expense under 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown - 
porcelain fused to high noble metal (D2750).   
Your complaint about the misleading information in the 2023 EOC 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 determination of refractive state (92015) provided on 
September 19, 2023.  
You asked the Plan to pay for a determination of refractive state (92015). You say that given the significant 
decline in your vision in the past 6 months, you are no longer able to drive at night. You also say you feel that 
the insurance should be covering the refractive test. The Plan denied your request. The Plan says the benefit for 
this refraction has been exhausted. 
 
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 eye examination (refraction) per calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules say that routine eye examinations are covered once 
per calendar year. The record shows that the eye refraction was exhausted on February 14, 2023. 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 September 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for Medicare Part B chemotherapy drug 
injection provided on July 20, 2023. 
 
You asked the Plan to reduce the coinsurance for Medicare Part B chemotherapy drug injection. You say that 
your maximum out-of-pocket was met with your previous treatments. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $1,483.01 coinsurance for chemotherapy injection. This total is less than 20% of 
the allowed amount for a Medicare Part B chemotherapy drug injection, as your maximum out-of-pocket was 
met with the processing of this claim. 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 reduce the coinsurance for Medicare Part B chemotherapy 
drug injection provided on July 20, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services received on August 15, 
2023. 
 You asked the Plan to pay for the paramedic intercept services. You say that the paramedic just showed up and 
you are not sure if they did anything. The Plan denied your request. The Plan says this is not a covered service 
under your ambulance benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services received on August 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve test strips. 
 
You asked the Plan to pre-approve test strips. You say that you would like to request reconsideration of the 
denied test strips and that the services requested are medically necessary. The Plan denied your request. The 
Plan says only the preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for test strips. Therefore, we decided that the Plan does not have to pre-approve test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided on July 24, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this was an emergency service, and you 
did not have the option to go to another provider. 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 the dental services provided on July 24, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided by a chiropractor on September 11, 
2020, to, January 4, 2021. 
 
You asked the Plan to pay for the office visits. You say that you have never been charged over $10 before this 
claim. The Plan denied your request. The Plan says the only covered chiropractic service is manual 
manipulation of the spine. 
 
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 visits provided by a chiropractor on September 11, 2020, to, 
January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from February 23, 2023, to 
March 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you changed your insurance company for the 
enhanced dental coverage but not want change providers. 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 the dental services provided from February 23, 2023, to March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown - porcelain/ceramic (D2740) provided on 
July 24, 2023. 
 
You asked the Plan to pay more for the dental service. You say that the dental office called the plan for your 
coverage for this procedure. You also say that you were told that you would be responsible for a copayment of 
$350 and were surprised to learn that the provider was out-of-network. The Plan denied your request. The Plan 
says your benefit for the requested service $1,000 dollar limit was met. 
 
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 service was exhausted on dates of service June 9, 2023, and July 24, 2023. 
Therefore, we decided that the Plan does not have to pay more for the crown - porcelain/ceramic (D2740) 
provided on July 24, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital inpatient care and the EEG provided on 
December 28, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you do not agree with the 
overpayment request. You say that the Plan should be responsible for the charges since hospice terminated on December 27, 2022. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 27, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital 
inpatient care and EEG provided on December 28, 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 you had a lung transplant and cannot stand for a long 
period without passing out. You say you are very worried and concerned for your health and were instructed to 
have inpatient rehabilitation as soon as possible. The Plan denied your request. The Plan says the notes do not 
show that your care specifically requires the involvement of a doctor in the field of Rehabilitation Medicine; 
the notes do not show that you have complex care needs that require a coordinated team approach; the notes do 
not show that you must have an intensive therapy program (3 hours a day, at least 5 days a week) in order to improve self-
care functioning.  Your medical and therapy needs could be met in a skilled nursing unit.  
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable. There are no complex nursing or rehabilitation needs. You do 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 therapy and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Medically necessary care can be provided in a different level of 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 continued inpatient admission from November 24, 
2023, forward. 
 
You asked the Plan to pre-approve continued inpatient admission from November 24, 2023, forward. You say 
that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 continued inpatient admission from 
November 24, 2023, forward. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the documentation from November 23, 
2023, described the patient without agitation, without acute changes in his blood testing, with stable vitals. 
Plans were made for disposition. Following November 23, 2023, the patient would have been appropriate for a 
lower level of care awaiting placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient admission from November 24, 2023, forward have not been 
met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient admission from 
November 24, 2023, forward.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing services. 
 
You asked the Plan to pre-approve the skilled nursing services. You say that the enrollee would like the benefit 
extended. The Plan denied your request. The Plan says the enrollee has exhausted the covered 100-day skilled 
benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 1, 2023, 
through November 8, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve the skilled nursing services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment without transport services 
received on July 24, 2023. 
 
You asked the Plan to pay for ambulance response and treatment without transport. You say that the services 
were medically necessary. The Plan denied your request. The Plan says without transport there are no covered 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 24, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without 
transport services received on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5298) provided on March 8, 2023. 
 
You asked the Plan to pay for hearing aids (V5298). You say that this provider is the provider recommended by 
the Plan. The Plan denied your request. The Plan says the hearing benefit is not covered if the services are not 
ordered through the Plan hearing designated vendor. 
 
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 services through a Plan hearing nationwide 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 (V5298) have not been met. Therefore, we decided that the Plan does not have to pay 
for hearing aids (V5298) provided on March 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left total knee arthroplasty (27447). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
 
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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for unilateral primary osteoarthritis of the left knee. She presented 
with right knee pain. She has lost over 15 pounds since her last office visit. The left knee pain is sharp and 
biting, achy, and painful. The symptoms are getting worse. The pain is rated at 6/10. The physical exam is 
unchanged.  
However, detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive, conservative care measures is not evident. Documentation does not evidence a trial and failure of 
visco supplementation injections. Additionally, the enrollees noted body mass index is 43.97 kg/m2. She is 
noted to be losing weight. A continued weight loss trial is typically indicated. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is 
no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested left total knee arthroplasty is not medically reasonable or 
necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a left total knee arthroplasty (27447).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the palliative treatment of dental pain  per visit 
(D9110), intraoral - periapical first radiographic image (D0220), extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) provided on August 10, 2023, and August 15, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you had a bad tooth that needed to be 
extracted and had no choice but to go to your local dentist for an extraction. You also say that the clinic only 
takes cash when work is performed and are seeking reimbursement. 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 the palliative treatment of dental pain  per 
visit (D9110), intraoral - periapical first radiographic image (D0220), extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) provided on August 10, 2023, and August 15, 2023.