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

 
We decided that the Plan does not have to pre-approve an initial 15 minutes of conscious sedation (D9239) and 
3 additional 15 minutes of conscious sedation (D9243). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says conscious sedation is not listed as a covered service. The Plan also says that any 
services not listed 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
initial 15 minutes of conscious sedation (D9239) and 3 additional 15 minutes of conscious sedation (D9243).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 21, 2020, and July 28, 
2020, by an out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says you did not request 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 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 July 21, 2020, 
and July 28, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
July 20, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider 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 out of network physician services provided to the enrollee on 
July 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent 300mg/2ml syringe for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent 300mg/2ml 
syringe for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) with related 
electronic connections (E2310) and red corvette wheel color (K0108). 
 
You asked the Plan to pre-approve the power seat elevation feature with required hardware and the requested 
wheel color. You say that it is felt that the requested chair should be approved. The Plan denied your request. 
The Plan says the power wheelchair and certain requested features were approved. However, the power seat 
elevation feature cannot be covered by Medicare. In addition, the wheel color is cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that only items with a primarily medical purpose can 
be covered as DME. Power seat elevation features are not considered primarily medical in nature. In addition, 
the requested wheel color is cosmetic and has no medical purpose. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation feature (E2300) with related electronic connections (E2310) and red 
corvette wheel color (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5050) provided June 15, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you were never told you had to get hearing aids 
from a specific supplier. The Plan denied your request. The Plan says the plan contract states the hearing aids 
must be obtained through a participating hearing aid supplier. 
 
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 they are obtained from a plan contracted supplier.  
 
We looked at the file and the Plan's rules. The hearing aids were not obtained from a plan contracted supplier. 
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 hearing aids (V5050) provided June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bariatric surgery consult. 
 
You asked the Plan to pre-approve a bariatric surgery consult. You say that you need this to lose weight. The 
Plan denied your request. The Plan says this is not covered for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that bariatric surgeries are covered for Medicare 
beneficiaries who have a body-mass index of at least 35, have at least one co-morbidity related to obesity, and 
have been previously unsuccessful with medical treatment for obesity. Treatments for obesity alone remain 
non-covered. 
 
We looked at the file and Medicare rules. The record does not show that you have a body-mass index of at least 
35 and co-morbidities related to obesity. Based on this information, we decided that Medicare rules for 
coverage of a bariatric surgery consult have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a bariatric surgery consult.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the requested CGM. You say that the requested device is medically 
necessary and should be covered. The Plan denied your request. The Plan says the criteria for coverage of a 
CGM are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the requested CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the outpatient rehab services provided from 
July 31, 2020, to August 24, 2020. 
 
You asked the Plan to waive the cost share for the services provided. The Plan denied your request. The Plan 
says the copays were 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 $40 
copay for outpatient rehab services.  
 
You have been asked to pay a $40 copay for each date of service. The services fall within the outpatient rehab 
services 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 cost share for the outpatient rehab services 
provided from July 31, 2020, to August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of tooth # 31 provided on June 16, 2020. 
 
You asked the Plan to pay for the dental service. You say that you have paid this dentist thousands of dollars 
that you did not expect. You say that if your tooth is abased and needs to be extracted then you should be paid 
for some of the charges. You also say that the dentist said there was an abased sac attached to the tooth when 
he pulled it. The Plan denied your request. The Plan says 1 extraction per lifetime is covered. The Plan says 
that the frequency limit for this service 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, the frequency limit of 1 extraction per 
lifetime has been exceeded. The record shows that the Plan paid for an extraction that you received on April 18, 
2001. Therefore, we decided that the Plan does not have to pay for the extraction of tooth # 31 provided on 
June 16, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 24 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. The Plan denied your request. The Plan says that the PT 
services are 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 PT visits. Our reviewer says that the 
requested PT visits are medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has weakness and spasticity of the lower extremities. The enrollee is unable to ambulate, but is able to 
bear weight. On October 29, 2020, the enrollee's static and dynamic sitting balance were continuing to improve 
due to exercises and core strengthening. The enrollee had gained range of motion. It is documented that the 
enrollee will continue to benefit to improve tone and spasticity, transfers, trunk stability, weight-bearing 
tolerance, balance, and functional independence. The requested therapy generally accepted as specific and 
effective therapy for the enrollee's condition and the clinical records support that the unique skills of a 
professional therapist are required. 
 
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 PT visits have been met. Therefore, we decided that the Plan has to pre-
approve 24 additional physical therapy (PT) visits.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 23, 2020, by an OON 
provider. 
 
You asked the Plan to pay for an injection of the sacroiliac joint. You say that you are submitting 
documentation to support the necessity of the service rendered. 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 June 23, 2020, 
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital hearing aids (V5258) provided on February 17, 2020. 
 
You asked the Plan to pay for hearing aids. You say that you were unaware you needed to use an in-network 
provider. The Plan denied your request. The Plan says hearing aids must be purchased in-network. 
 
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 network hearing aid provider. 
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Specifically, you did not go to an in-network provider. Therefore, 
we decided that the Plan does not have to pay for digital hearing aids (V5258) provided on February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete 
series of x-rays (D0210) provided on July 23, 2020. 
 
You asked the Plan to pay for the dental services. You say that the dental office advised that they confirmed 
with the Plan that the services would be covered. You say that you trusted that the dental office was completely 
honest. You also say that the services should be covered. The Plan denied your request. The Plan says 1 
comprehensive oral exam and 1 complete series of x-rays are covered every 3 plan years. The Plan also says 
that the frequency limits fort these services have 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, the frequency limits for these services 
have been exceeded. The record shows that the Plan paid for a comprehensive oral exam and a complete series 
of x-rays that you received on June 17, 2019. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) and the complete series of x-rays (D0210) provided on July 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the cardiovascular procedure provided on 
October 6, 2020. 
 
You asked the Plan to reduce the coinsurance for the cardiovascular procedure. You say that you stayed 
overnight and were expecting a $380 copayment. You say that this should be reprocessed as an inpatient 
admission. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance per visit for outpatient surgery. 
 
You have been asked to pay $4,497.79, which is 20% of the allowed amount for the cardiovascular procedure. 
The allowed amount is $22,488.93 (20% x $22,488.93 = $4,497.79). The cardiovascular procedure falls within 
the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers" benefit category. The records show that this was an outpatient procedure.  
 
 
 
 
 
 
 
 
 
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 the cardiovascular procedure provided on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower limb prosthesis (L5981) 
 
You asked the Plan to pre-approve the prosthesis. You say that the K3 level prosthesis is medically necessary. 
The Plan denied your request. The Plan says the type of prosthetic requested exceeds the enrollee's functional 
needs. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design features of a given type of prosthetic. 
 
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 prosthesis. Our reviewer says that 
the requested prosthesis is not medically necessary. Our physician reviewer found there is no clinical 
documentation in the medical records provided to support the functional level designated by the prosthetist. 
The requested K3 components exceed the enrollee's needs and are not medically necessary or reasonable. 
 
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 prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lower limb prosthesis (L5981)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on  
August 24, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the services provided do not meet criteria 
for coverage under the members contractual policy. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan?s rules apply in this case.  
 
We looked at the file and the Plan?s rules. Based on this information, we decided that the Plan?s rules for 
coverage of the acupuncture treatment have not been met.  
 
 
 
Specifically, the acupuncture was not provided by a physician licensed to perform the service. This means that 
the acupuncture services are not eligible for coverage by the Plan. Additionally, these services were not 
provided for treatment of chronic lower back pain and are therefore, also not eligible for coverage by Medicare. 
Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) 
provided on August 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0432) provided on July 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the 
transportation was for a medical emergency. The Plan denied your request. The Plan says the services were not 
furnished under contract with a volunteer ambulance company. 
 
The Plan must follow Medicare rules. 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 under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the rendering provider does not have a contract with the volunteer ambulance 
company that provided the transport services. Therefore, we decided that the Plan does not have to pay for 
ambulance services (A0432) provided on July 25, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven (7) occupational therapy home visits. 
 
You asked the Plan to pre-approve the visits. You say that the services are necessary. The Plan denied your 
request. The Plan says since you have already had skilled occupational therapy visits, you seem to be at your 
functional baseline and the occupational therapist was planning on weekly visits to work on exercises. The Plan 
states skilled occupational therapy visits are not required for a home exercise program. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 visits. Our physician reviewer found 
the requested additional therapy is not generally accepted as specific and effective therapy for your condition. 
You have had prior therapy for this condition and it does not appear that you require the unique skills of a 
professional therapist 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. You and caregivers were given 
instruction on an independent exercise program and safety precautions. The specialized skill, knowledge and 
judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve seven (7) occupational therapy home visits.