Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis and insert provided on May 1, 2020. 
 
You asked the Plan to pay for the ankle foot orthosis and insert. You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says the billed supply codes cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket 
did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the 
Delivery Ticket. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis and insert 
provided on May 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2392) provided on June 29, 2020.

You asked the Plan to pay for the dental service. You say that it is your understanding that your insurance covers 2 fillings per calendar year. You say that of the 3 fillings you received this year, 2 have been denied. You say that 1 filling was to replace an existing one. The Plan denied your request. The Plan says 2 fillings per calendar year are covered. The Plan says that the 2 fillings you received on January 29, 2020 were paid. The Plan also says that the fillings in January satisfied this benefit.

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 2 fillings per calendar year has been exceeded. Therefore, we decided that the Plan does not have to pay for the filling (D2392) provided on June 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive audiometry threshold evaluation and 
speech recognition and the tympanometry services provided on January 23, 2020 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for the comprehensive audiometry threshold evaluation and speech recognition and 
the tympanometry services. You say that you would like the plan to reconsider their denial. The Plan denied 
your request. The Plan says the services provided are not a covered benefit. 
 
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 comprehensive audiometry threshold 
evaluation and speech recognition and the tympanometry services provided on January 23, 2020 by an out of 
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 
22, 2020. 
 
You asked the Plan to pay for the preventive procedure and comprehensive oral evaluation. You say that you 
believe a periodic oral evaluation was the proper evaluation that should have been coded for. You also say that 
you are an established patient at this provider's office, and it was not an initial examination. The Plan denied 
your request. The Plan says comprehensive oral evaluations are limited to 1 time every 3 calendar years, and 
you already had this service done during that time. 
 
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) is limited to 1 per 3 calendar years. The record shows that you received a comprehensive oral 
evaluation (D0150) on May 29, 2019, and your comprehensive oral evaluation (D0150) benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) provided on July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, alveoloplasties in conjunction with 
extractions, endosteal implants, and radiographic/surgical implant index provided on December 3, 2019. 
 
You asked the Plan to pay for the extractions, alveoloplasties, endosteal implants, and radiographic/surgical 
implant index. You say that these services were needed due to radiation treatments that you received. The Plan 
denied your request. The Plan says you do not have dental coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the extractions, alveoloplasties in 
conjunction with extractions, endosteal implants, and radiographic/surgical implant index provided on 
December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 3, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services rendered by non-participating 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 
laboratory 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 laboratory services provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-rays 
(D0220) and unspecified preventative procedure (D1999) provided on June 25, 2020. 
 
You asked the Plan to pay for these services. You say that you would like this claim reviewed and covered. The 
Plan denied your request. The Plan says that these are not covered services. 
 
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 
limited oral evaluation (D0140), the periapical x-rays (D0220) and unspecified preventative procedure (D1999) 
provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chiropractic services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON chiropractic services. You say that you were told you could get a 
network exception. The Plan denied your request. The Plan says the requested services are available in-
network. 
 
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 
the chiropractic services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dentures provided on June 17, 2020. 
 
You asked the Plan to pay for the dentures. You say that you were not told that this provider was out of 
network. The Plan denied your request. The Plan says that these services are not covered out of network. 
 
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 Plan covers the dentures 
when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The file indicates the dentures were not provided by a participating 
provider. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been 
met. Therefore, we decided that the Plan does not have to pay for the dentures provided on June 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional skilled nursing visits (G0299, G0300).

You asked the Plan to pre-approve the additional skilled nursing visits. You say that you have a port in your heart that requires the dressings and a needle to be changed so you require hospital level sterilization to avoid serious life threatening infections. The Plan denied your request. The Plan says the additional skilled nursing visits is not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 additional skilled nursing visits. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the documentation doesn't support that the enrollee requires additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration.  The enrollee has been medically stable and has home health nursing and home health aide hours and services in place that can effectively treat the member.  The documentation does not support that additional nursing services are medically 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 the additional skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional skilled nursing visits (G0299, G0300).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for laboratory services provided on May 13, 2019. 
 
You asked the Plan to hold you harmless for the laboratory services. You say that you would like 
reconsideration because you are being balance billed by the provider. The Plan denied your request. The Plan 
says that this is not a Medicare covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory services by a contract provider. The file does not show that the Plan 
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for laboratory services provided on May 13, 2019.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) and the 
subsequent extended ophthalmoscopy (92226 LT, RT) provided. 
 
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 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. During the election, fee-for-service Medicare also covers attending physician services and all care 
unrelated to the terminal illness until the first day of the month following the month in which hospice was 
revoked or discharged. 
 
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 Medicare Hospice benefits ended on November 19, 2019. 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 subsequent nursing 
facility care, per day (99308) and the subsequent extended ophthalmoscopy (92226 LT, RT) provided.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $258.48 copayment charged for ambulance transport 
provided on May 30, 2020. 
 
You asked the Plan to waive this copayment. You say that you think this transport should be covered by the 
Plan. The Plan denied your request. The Plan says you are being charged $258.48, which is less than the 
normal copayment expectation. This copayment was charged based on the services provided and the Plan 
contract agreement. 
 
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 $265 
copayment for each one-way ambulance transport.  
 
You have been asked to pay the less than the normal copayment 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 $258.48 copayment charged for ambulance transport provided 
on May 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the over-the-counter (OTC) purchases from 
February 20, 2020 to May 26, 2020. 
 
You asked the Plan to reimburse you for these services. You say that you would like reimbursement. The Plan 
denied your request. The Plan says the request was submitted past the 90 day timeframe. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and these 
services is an OTC item. The contract with the Plan states that there is a $30 benefit every month for eligible 
OTC items and that receipts must be submitted within 90 days of the receipt date. 
 
We looked at the file and the Plan's rules. The file shows that you did not submit your receipt for 
reimbursement of OTC items within 90 days, as required by the Plan. Based on this information, we found that 
the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to reimburse you for the over-the-counter (OTC) purchases from February 20, 2020 to May 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you are requesting a 
reconsideration of the Plan?s denial. The Plan denied your request. The Plan says you have exhausted the 
routine transportation benefit. 
 
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 150 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.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living services provided on June 16, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for assisted living services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the referring facility is also out-of-network. 
 
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 assisted living services provided on June 16, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you are having 
financial difficulty pay for these services. The Plan denied your request. The Plan says that the cost-share 
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 day for days 1 to 5 each time you are admitted for Medicare-covered hospital care.  
 
You have been asked to pay an $800 copayment for the inpatient hospital services. The inpatient hospital 
services fall within the days 1 to 5 each time you are admitted for Medicare-covered hospital 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 inpatient hospital services provided.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for polycarbonate lenses and anti-reflective coating provided on August 
24, 2018. 
 
You asked the Plan to pay for the polycarbonate lenses and anti-reflective coating. You say that you've spoken 
with the participating provider who has assured you that they would resubmit the claim. The Plan denied your 
request. The Plan says that the claim was submitted with an incorrect modifier. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the polycarbonate lenses and anti-reflective coating by a contract provider. The file does 
not show that the contracted provider, who is considered an agent of the Plan, ever provided notice that the 
upgrades in dispute would not be covered. Under Medicare rules, this means the polycarbonate lenses and anti-
reflective coating is considered approved by the Plan. Therefore, we decided that the Plan has to pay for 
polycarbonate lenses and anti-reflective coating provided on August 24, 2018.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have had fallen many times. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 27, 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 services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on February 27, 2020.