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

 
We decided that the Plan does not have to pay for the prophylaxis provided on August 27, 2020. 
 
You asked the Plan to pay for the prophylaxis. You say that you were told that you had money left in your 
annual maximum that would cover your 6 month cleaning. You also say that you miscalculated the date your 
insurance became active by two days, which was September 1, 2020. The Plan denied your request. The Plan 
says you were made aware that the added dental rider would be effective September 1, 2020. The Plan also 
says that you were not eligible for coverage on this date of service because your dental rider was not active. 
 
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 prophylaxis provided on 
August 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elevating legrests. 
 
You asked the Plan to pre-approve elevating legrests. You say that this is medically necessary. The Plan denied 
your request. The Plan says that you do not meet criteria for elevating legrests. 
 
The Plan follows Medicare rules. Medicare rules say that elevating legrests are covered if the criteria listed 
above has been met. 
 
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 elevating legrests. Our reviewer says 
that elevating legrests are not medically reasonable and necessary in this case. The documentation does not 
reveal a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the 
knee, significant edema of the lower extremities that requires an elevating legrest, or a reclining back on the 
wheelchair. Our physician reviewer found that your condition does not meet Medicare criteria for elevating 
legrests. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of elevating legrests have not been met. Therefore, we decided that the Plan does 
not have to pre-approve elevating legrests.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 29, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed were processed correctly. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the allowed amount for 
these services was $441.92. The enrollee's primary insurer paid $451.40. Therefore, no additional payment can 
be made. As the secondary insurer, the Plan cannot be held responsible for the ambulance services until the 
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to 
pay for the ambulance services provided on October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection between a controller and two or 
more power options (E2311). 
 
 
 
You asked the Plan to pre-approve an electrical connection between a controller and two or more power 
options. You say that this is medically necessary. The Plan denied your request. The Plan says it is not 
necessary for the enrollee to control power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that an electrical connection between a controller and 
two or more power options is covered when medically necessary for functions 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 an electrical connection between a 
controller and two or more power options. Our reviewer says that the requested item is not considered 
medically reasonable and necessary in this case. Our physician reviewer found based on the medical records 
provided there is no documentation that the item at issue in this case is medically reasonable and necessary to 
control two or more motors from a single interface. There is no medical reason in the available records why the 
power options need to be controlled through the joystick. Records indicate the enrollee has 3/5 to 4/5 upper 
extremity strength and is able to manage grooming, hygiene, toileting and meal preparation thus demonstrating 
strength and coordination to control the power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical connection between a controller and two or more power options 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical connection 
between a controller and two or more power options (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered on December 8, 
2019. 
 
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 procedure code 95951 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95951 is long-term EEG monitoring with video. 
 
We find that CPT code 95951 is not supported in the medical record. Specifically, there is no documentation of 
a long-term EEG with video for the date of service at issue. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the electroencephalogram (EEG) rendered on December 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999) provided on 
June 11, 2020. 
 
You asked the Plan to pay for the unspecified preventive procedure. You say that you were advised by a plan 
representative that this provider was in network. You say that the services should be covered based on the 
information you received. The Plan denied your request. The Plan says unspecified preventive procedure 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 unspecified preventive procedure is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventive procedure (D1999) provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services provided on May 7, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for mental health services. You say that these services were provided in good faith. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these 
services can be provided 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 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 mental health services provided on May 7, 2019 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 6, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
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 laboratory services at issue in this appeal were 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 provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 19, 2019. 
 
You asked the Plan to pay for the physician's 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 physician's services provided on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you accidentally broke your 
denture, and cannot afford to pay for a new one. The Plan denied your request. The Plan says you have 
received a partial or full denture in the last 96 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, mandibular dentures are covered once 
every 96 months. The record shows that you received a mandibular partial denture on April 25, 2017, and your 
mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services related to dental extractions 
provided on January 31, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you fell and broke your tooth in 
December 2016. You say that you needed to have dental surgery to remove your teeth because of medical 
issues caused as a direct result of your fall. You say that the dentist would not do the procedure in the office. 
You also say that you are unable to pay this bill. The Plan denied your request. The Plan says dental services 
are not covered. The Plan says that the related outpatient services are not covered either. 
 
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 outpatient hospital services related to dental 
extractions provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 17, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
physicians 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 physician's services provided on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on June 8, 2019. 
 
You asked the Plan to pay for these services. You say that this claim was filed timely and should be reviewed 
under the enrollee's Medicare and Medicaid benefits as they are dual eligible. The Plan denied your request. 
The Plan says this claim was not filed timely for Medicare consideration. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for these 
services was not properly filed until August 1, 2020. This means that more than one calendar year from the date 
of service had passed before a claim was filed. The Plan is within their right not to review this claim for 
Medicare coverage. We do not have jurisdiction over Medicaid benefit review. Therefore, we decided that the 
Plan does not have to pay for services provided to the enrollee on June 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed 
conservative therapies including medications, injections, and physical therapy. The Plan denied your request. 
The Plan says the enrollee has not had physical or psychological therapy, nor surgical treatment. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. She has had epidural steroid injection and medial 
branch blocks, which was followed by radiofrequency ablation. She had a psychological evaluation and 
clearance. The records do not show that the enrollee has had an evidence-based indication for a spinal cord 
stimulator (SCS). The enrollee does not meet the coverage criteria for a SCS trial.  Therefore, the requested 
service is deemed 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence 
of four-week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week 
trial of conservative therapy demonstrating failed response to treatment is required. 
 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular home usage of conservative therapy including compression garments, exercise and 
elevation. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not 
covered by Medicare to prevent deep vein thrombosis during and/or following surgery but additionally, PCDs 
billed by E0675 are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. PCDs billed by E0675 are 
not covered. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device.
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 additional routine transportation trips. You say that you need these trips to 
get to appointments. The Plan denied your request. The Plan says that you have reached your maximal 
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 forty (40) 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee requires this device. 
The Plan denied your request. The Plan says the pneumatic compression device is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation did not reflect that the enrollee had 
lymphedema or venous stasis ulcers. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.