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

We decided that the Plan does not have to pay for the hearing aids purchased July 4, 2020, from an out of 
network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you would like this request reviewed and approved 
for reimbursement. The Plan denied your request. The Plan says hearing aids are only covered when obtained 
from a contracted provider. 
 
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 plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a contracted provider with the Plan.  
 
We looked at the file and the Plan's rules. The case information indicates that hearing aids are only covered 
when purchased from a contracted provider with the Plan. Based on this information, we decided that the Plan's 
rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to 
pay for the hearing aids purchased July 4, 2020, from an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460) and problem focused limited 
oral evaluation (D0140) provided on June 26, 2020. 
 
You asked the Plan to pay for the pulp vitality tests and problem focused limited oral evaluation. You say that 
these services were necessary. The Plan denied your request. The Plan says pulp vitality tests is not a covered 
benefit. The Plan also says that the problem focused limited oral evaluation exceeds the frequency limitation in 
your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, pulp vitality tests is not among those 
covered under this benefit. The contract also clearly states that problem focused limited oral evaluation 
(D0140) is limited to one procedure per plan year. The record shows that you received a problem focused 
limited oral evaluation (D0140) on June 24, 2020, and your problem focused limited oral evaluation (D0140) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the pulp vitality tests 
(D0460) and problem focused limited oral evaluation (D0140) provided on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on July 28, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you assumed these services would be covered by your dental plan. You also say that you were unaware 
that there was a maximum allowed per period. The Plan denied your request. The Plan says these services 
exceed the maximum allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation (D0150) and a complete series of 
intraoral x-rays (D0210) on March 29, 2018, and your comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) 
provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on July 29, 2020. 
 
You asked the Plan to pay for hearing aids. You say that you were unaware you were required to go through 
the Plan's network. The Plan denied your request. The Plan says there is no coverage if hearing aids are 
received from out-of-network providers and not registered in advance. 
 
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 plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when you contact the Plan to register prior to purchasing any hearing aids.  
 
We looked at this physician's review, 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. Specifically, you received you hearing aids out-
of-network without registering in advance. Therefore, we decided that the Plan does not have to pay for hearing 
aids provided on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), prophylaxis 
(D1110), and the bitewing x-rays (D0274) provided on June 24, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that the services were rejected for 
payment. You also say that you were advised that the Plan would pay you the rates they pay for Medicare. The 
Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says 
that payment cannot be made for dental services that you receive from a dental provider who has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on June 
24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 26, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
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 March 26, 2020. 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 the ambulance services provided on March 26, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on June 1, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for psychotherapy services provided on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased June 18, 2020, from an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you would like the claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says hearing aids purchased from an OON 
provider will not be covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plan's hearing aid vendor.  
 
We looked at the file and the Plan's rules. The case information indicates that the hearing aids were purchased 
from an OON provider and not from the Plan's hearing aid vendor. Based on this information, we decided that 
the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does 
not have to pay for the hearing aids purchased June 18, 2020, from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on July 30, 
2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you would like this claim 
to be paid in full. You also say that you have supplemental coverage under your dental plan. The Plan denied 
your request. The Plan says the benefits for this service have been satisfied and the frequency limitation has 
been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on July 30, 
2020, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have 
to pay for the additional intraoral periapical x-ray provided on July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, complete 
maxillary denture, and complete mandibular denture provided on July 8, 2020 by an OON provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, complete maxillary denture, and 
complete mandibular denture. You say that you and the office receptionist contacted the Plan and were told that 
you were covered up to $3,000. The Plan denied your request. The Plan says these services were rendered by 
an OON provider. The Plan also says that services performed by an OON provider are not covered because 
your plan does not have OON benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
covered when they are received OON. The records show that you were advised of your dental benefits, and 
provided with a list of in-network providers on June 2, 2020. Your provider was advised that the provider is 
OON and that your plan has no coverage at all for OON providers. Therefore, we decided that the Plan does 
not have to pay for the problem focused limited oral evaluation, complete maxillary denture, and complete 
mandibular denture provided on July 8, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requirements of the LCD have not been met. 
 
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 injections. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the physical exam notes pain on forward flexion but range of motion seems intact. Imaging 
describes very mild facet arthropathy. It is unclear whether the enrollee's physical therapy was directed at the 
neck. Therefore, the request does not meet the criteria of the LCD and the request is deemed not medically 
reasonable or necessary at this point. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan 
denied your request. The Plan says you exceeded the allowed transports. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant removal (D6100) for teeth # 14 and 15 provided 
on December 5, 2019. 
 
You asked the Plan to pay for the dental services. You say that your implant was infected. You say that your 
son was advised by a plan representative before you received the service that implants were not covered. You 
say that if the implants had not been removed, then a hospitalization may have been needed to treat the 
infection. The Plan denied your request. The Plan says implant removal is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
implant removal (D6100) for teeth # 14 and 15 provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system 
(E2300) is statutorily non-covered by Medicare and the Plan. 
 
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. Medicare specifically excludes coverage of power seat elevation 
systems coded as E2300. Based on this information, we decided that Medicare rules for coverage of a power 
seat elevation feature (E2300) have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power seat elevation feature (E2300).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided February 5, 2020, to February 
15, 2020. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-
for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or 
revocation. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the medical services provided February 5, 2020, to February 
15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of physical therapy visits. 
 
You asked the Plan to pre-approve the continuation of physical therapy visits. You say that the requested 
continuation of physical therapy visits is medically necessary. The Plan denied your request. The Plan says the 
requested continuation of physical therapy visits is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 continuation of physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the enrollee is with a past medical 
history of chronic incomplete spastic tetraplegia who has received a total of 26 physical therapy treatments 
since 06/03/2020. One additional physical therapy treatment session has been requested. Based on the medical 
records provided there is no documentation that the requested therapy is generally accepted as specific and 
effective therapy for the enrollee's condition. Based on the available records the enrollee appears to have 
plateaued with therapy. Further therapy at this point does not appear to be likely to achieve any significant 
improvement in the enrollee's symptoms or functional status. There is no documentation that the unique skills 
of a professional therapist are required to safely and effectively provide treatment, that the services can be 
safely and effectively performed only by a therapist or under the supervision of a therapist. 
 
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 continuation of physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the continuation of physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (A9276 and A9277). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says neither Medicare or the health plan covers this for everyday use or over a long period of 
time. 
 
The Plan must follow Medicare rules. Medicare rules say that A9276 and A9277 are not covered.  
 
The requested monitor is coded with A9276 and A9277, which is not covered. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (A9276 and A9277).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the out of network cost share for the comprehensive oral 
evaluation (D0150), prophylaxis (D1110), and the fluoride varnish application (D1206) provided on July 9, 
2020. 
 
You asked the Plan to pay the out of network cost share for the dental services. You say that a plan 
representative advised that the services would be covered. The Plan denied your request. The Plan says the 
provider in this case is not a network provider. The Plan says that services are paid according to a maximum 
allowable fee schedule and the member is responsible for all fees in excess of this amount from the billed 
amount. The Plan also says since the provider was out of network, the difference of billed amount and allowed 
amount became the enrollee's responsibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the difference of the billed amount and 
allowed amount becomes your responsibility when you receive dental services out of network. Therefore, we 
decided that the Plan does not have to pay the out of network cost share for the comprehensive oral evaluation 
(D0150), prophylaxis (D1110), and the fluoride varnish application (D1206) provided on July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder orthosis provided on August 4, 2020. 
 
You asked the Plan to pay for the shoulder orthosis. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
shoulder orthosis. We found no exception that would require the Plan to pay for this item. Therefore, we 
decided that the Plan does not have to pay for a shoulder orthosis provided on August 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an out-of-network provider. 
 
You asked the Plan to pre-approve the referral. You say that you did not like the in-network provider. The Plan 
denied your request. The Plan says you can be seen by an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral for an out-of-network provider.