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

We decided that the Plan does not have to pre-approve the complete denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the complete denture - mandibular. You say that you accidentally threw out 
your dentures and need them replaced. The Plan denied your request. The Plan says these services are only 
covered once every 60 months. 
 
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. The Plan covers the complete 
denture - mandibular when the services are medically necessary and reasonable.  
 
We looked at this the file and Medicare rules. The information in the case file indicates that you previously had 
these services provided on December 31, 2019, and October 5, 2020. Based on this information of previous 
services rendered within 60 months, we decided that the Plan's rules for coverage of the complete denture - 
mandibular have not been met. Therefore, we decided that the Plan does not have to pre-approve the complete 
denture - mandibular (D5120).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July 
20, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that the transfer to the 
emergency room was medically necessary. You say that you had no control over the provider that rendered the 
service and the claim should be processed in-network. The Plan denied your request. The Plan says the 
copayment applied 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 $200 
copayment per date of service regardless of the number of trips for ground ambulance services. 
 
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls 
within the "Ambulance services" benefit category. The records show that the claim processed in-network. 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 ambulance transport provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a tertiary dermatology consultation to be provided by an in-network 
provider
 
You asked the Plan to pre-approve a tertiary dermatology consultation. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the requested services can be provided 
by a non-tertiary provider. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a tertiary dermatology consultation. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found you have facial lipodystrophy. The documentation shows that you are requesting 
a dermatology consultation for scupltra. The documentation supports that you were previously treated by this 
provider. The request is considered continuity of treatment. Therefore, you meet criteria for the requested 
services. 
 
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 tertiary dermatology consultation have been met. Therefore, we decided that 
the Plan has to pre-approve a tertiary dermatology consultation to be provided by an in-network provider. 
 
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: 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 would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 you were admitted for COVID 19 pneumonia. Your medical conditions are stable. 
The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation 
therapy program. Your therapy needs can be met at a lower 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 IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that since you fell, you have had acute changes in 
mobility and you are in need of IRF care to regain maximum function and return to daily living. The Plan 
denied your request. The Plan says based on Medicare guidelines, the request for an IRF admission does not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. Based on the 
medical documentation, your medical status does not clearly reveal whether you are medically stable for 
transfer to an IRF. Functionally, you may benefit from multiple therapies such as physical and occupational 
therapy but the documentation does not support that you can tolerate an 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the periapical x-ray 
(D0220) provided on July 28, 2020. 
 
You asked the Plan to pay for the dental services. You say that you called the plan to change your address on 
file. You say that you transferred to the dental plan and were advised that your dental provider is not in 
network. You say that you did not trust the information that you were given. You also say that you were in 
pain. The Plan denied your request. The Plan says the dental provider in this case is not a network provider. 
The Plan also says that dental services that you receive out of network are not covered. 
 
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, dental services that you receive out of 
network are not covered. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) and the periapical x-ray (D0220) provided on July 28, 2020.  
 
Your complaint about feeling you had been deceived by the plan representative 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the stockings to maintain 
lymphedema. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the sleep study (95806) provided on July 22, 2020. 
 
You asked the Plan to pay for the sleep study. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. Specifically, the Plan denied payment for CPT code 95806 because the diagnosis 
code billed on the claim, G47.34 is not listed as an approved diagnosis code per LCA A56923. After review of 
LCA A56923, it was found that diagnosis code G47.34 is indeed a covered diagnosis code for CPT code 
95806. We find that the Plan has not supported their reasoning for the denial of payment based on Medicare 
guidelines. Therefore, we decided that the Plan has to pay for the sleep study (95806) provided on July 22, 
2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4267) and bone 
replacement graft for ridge preservation (D7953) provided on August 7, 2020. 
 
You asked the Plan to pay for the guided tissue regeneration and bone replacement graft for ridge preservation. 
You say that the services provided should be covered under your supplemental rider. The Plan denied your 
request. The Plan says these services are not covered under your supplemental rider. 
 
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 
guided tissue regeneration (D4267) and bone replacement graft for ridge preservation (D7953) provided on 
August 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you are appealing. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the crown (D2740) provided on June 8, 2020. 
 
You asked the Plan to pay the full amount for the dental service. You say that this is the first time that you have 
had an issue with the Plan. You say that since you have always had excellent services from the Plan, this must 
be a clerical error. You say that you have only had 1 crown on this tooth. You also say that this bill provides a 
financial challenge for you. The Plan denied your request. The Plan says there is a 50% coinsurance for 
crowns. The Plan also says that the claim was processed correctly. 
 
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, there is a 50% coinsurance for crowns. 
The record shows that the Plan reprocessed the claim and has paid 50% of the allowed amount for the crown. 
Coinsurance is a contractual obligation you agreed to when you enrolled in the Plans dental coverage. 
Therefore, we decided that the Plan does not have to pay the full amount for the crown (D2740) provided on 
June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 1, 2020, by an OON 
provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that these medically necessary services 
were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
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 has network providers 
available who can provide 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 the medical services provided on April 1, 2020, by 
an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from May 11, 2020, 
through May 29, 2020. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration 
because this claim was billed correctly. The Plan denied your request. The Plan says these services are not 
covered in a member's residence. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the record indicates that these 
services were rendered in the member's residence. These services are not covered when rendered in the 
member's residence. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided from May 11, 2020, through May 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve portable oxygen concentrator. 
 
You asked the Plan to pre-approve the DME). You say that when you leave your home it is not feasible for you 
to pull the oxygen container. The Plan denied your request. The Plan says oxygen device when the second item 
performs the same function as the one currently provided to the enrollee.  There is no medical documentation to 
support the member's need for two oxygen concentrators. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The Health Plan does not cover 
duplicate or redundant DME such as oxygen device when the second item performs the same function as the 
one currently provided to the enrollee. There is no medical documentation to support the need for two oxygen 
concentrators. Therefore, we decided that the Plan does not have to pre-approve portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the service is not a covered benefit 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 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. This service is not listed in the member's handbook as a covered 
benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve core 
buildup, including any pins when required (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power wheelchair (Power Mobility device or PMD) 
provided by on July 8, 2020. 
 
You asked the Plan to pay for the PMD. You say that the claim should be paid. The Plan denied your request. 
The Plan says the enrollee does not meet coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the PMD. Our reviewer says that the service 
is not medically necessary. Our physician reviewer noted that the enrollee has personal mobility deficit that is 
impairing her MRADLs. The enrollee's condition is not able to be ameliorated by a walker, cane or manual 
wheelchair but there is no documentation indicating that the enrollee is capable of safely operating the PMD. 
 
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 PMD have not been met. Therefore, we decided that the Plan does not have 
to pay for a power wheelchair (Power Mobility device or PMD) provided by on July 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on August 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy. 
 
You asked the Plan to pre-approve the physical therapy. You say that you would like reconsideration because 
you suffer severe back pain and an interruption to your physical therapy will have an adverse effect on your 
health. The Plan denied your request. The Plan says additional physical therapy 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 the physical therapy. 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 there is no documentation that the specialized skill, knowledge and 
judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the 
member's current condition or to prevent or slow further deterioration. 
 
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 physical therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy.