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

 
We decided that the Plan does not have to pre-approve dental services (D0230 - teeth #8, 11, 15, 24, 27, 28 and 
D0220) received on January 15, 2020. 
 
You asked the Plan to pre-approve the services. You say that the plan should reconsider coverage. The Plan 
denied your request. The Plan says this is not a covered 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. The Plan covers D0220 and 
D0230 twice per year.  
 
The maximum benefit for this type of dental x-ray had been paid for 2020. Based on this information, we 
decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve dental services (D0230 - teeth #8, 11, 15, 24, 27, 28 and D0220) received on 
January 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the physical therapy (PT) services 
rendered on August 5, 2020 to August 19, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you were told by the provider that 
there was no copayment. The Plan denied your request. The Plan says the copayments 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 $30 
copayment for each Medicare-covered physical therapy and/or speech and language pathology visit.  
 
Review of the file shows that you had four PT visits from August 5, 2020 to August 19, 2020. You have been 
asked to pay a $30 copayment per date of service for these services, for a total of $120. These services fall 
within the Medicare-covered physical therapy and/or speech and language pathology visit 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. The Plan cannot be held 
responsible for misinformation given by a provider regarding your cost sharing responsibility. Therefore, we 
decided that the Plan does not have to waive the copayments for the physical therapy (PT) services rendered on 
August 5, 2020 to August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the allergy test provided on February 24, 
2020. 
 
You asked the Plan to waive the copayment for the allergy test (95044). You say that there should only be one 
copayment for the visit. The Plan denied your request. The Plan says you were charged this coinsurance 
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 $50 
copayment for Specialist Visit. The rules also state that providers may bill services with a -25 modifier if the 
service billed with the modifier indicates a distinct procedural service. 
 
You have been asked to pay a $50 copayment for the allergy test (95044). The allergy test (95044) falls within 
the Specialist Visit benefit category. This code is payed separately under the physician fee schedule. 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 allergy test provided on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam (92004) provided on August 31, 2020, 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the medical eye exam. You say that you do not understand why you would need 
a referral. The Plan denied your request. The Plan says these services were not urgent or emergent and prior 
authorization was not obtained. 
 
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 had network providers 
available who could have provided 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 eye exam (92004) provided on August 
31, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the x-rays provided on August 17, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you went to get your teeth cleaned 
and x-rays. You say that the provider would not do a cleaning because you had periodontal disease. You say 
that you had to pay $35 for this visit. You say that you went to another dentist in September who said you did 
not have gum disease and who cleaned your teeth. You say that you had to pay another $35 for this visit. You 
also say that you should be refunded the $35 you had to pay on August 17, 2020. The Plan denied your request. 
The Plan says there is a $35 copayment for Medicare-covered dental services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to reimburse you 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. The copayment 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 reimburse you for the x-rays 
provided on August 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips. 
 
You asked the Plan to pre-approve additional mileage for routine transportation trips. You say that the 
additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage 
exceeds the benefit limit. Therefore, coverage criteria has not been met. 
 
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 60 one-way transportation trips per calendar year when each one-way trip 
does not exceed 75 miles 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 mileage for routine transportation trips.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network mental health care provided on September 17, 2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network mental health 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 had network providers available who could have provided 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 
mental health care provided on September 17, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on July 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the claim was not 
billed in accordance with CMS guidelines. 
 
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. The Plan indicates that the claim was not billed in accordance with CMS 
guidelines, and therefore cannot be paid. The Plan has not provided a detailed description of which Medicare 
guidelines the claim fails to adhere to. Without a description as to why the services cannot be paid, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided on July 
1, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on September 1, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you could not be transported to emergency 
without having a ride home. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 1, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 1, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET CT scan from the skull base to mid-thigh. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 PET CT scan from the skull base to 
mid-thigh. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
medical necessity of a PET/CT scan in an enrollee without a known malignancy has not been established. 
 
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 PET CT scan from the skull base to mid-thigh have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found skilled nursing and skilled therapy services are 
not required on a daily basis and as a practical matter this enrollee does not require the necessary services on an 
inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services received from January 21, 2020 to January 
31, 2020. 
 
You asked the Plan to pay for the services. You say that you did not know the provider was not in-network. 
The Plan denied your request. The Plan says the provider is 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 had network providers 
available who could have provided 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 vision services received from January 21, 2020 to 
January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for total electric hospital bed (E0265) purchased December 2, 
2018 
 
You asked the Plan to pay for total electric hospital bed. You say that attached is supporting information that 
will be helpful in processing for reimbursement. The Plan denied your request. The Plan says this item is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for total electric hospital bed 
(E0265) purchased December 2, 2018
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
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 12 one-way transportation 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 (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eyewear rendered on August 5, 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 services from an out-of-network provider are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine eyewear from a network provider only. 
 
We looked at the file and the Plan's rules. The file shows that you did not receive routine eyewear from a 
network provider. Based on this information, we decided that the Plan's rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the routine eyewear rendered 
on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary interim partial denture provided on July 1, 
2020. 
 
You asked the Plan to pay for the maxillary interim partial denture. You say that you are not able to chew 
without a partial. The Plan denied your request. The Plan says you are not 17 years old or under, have not had 
the tooth extracted, and are not in the healing stage after extraction. The Plan also says that you do not meet the 
criteria for this type of denture. 
 
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. There were no records provided showing you recently had an 
extraction. Therefore, we decided that the Plan does not have to pay for the maxillary interim partial denture 
provided on July 1, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided October 18, 2020 to October 
20, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says that the services rendered were not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented to the emergency department on October 18, 2020 for the evaluation of 
bilateral leg pain from the knee down, generalized weakness, fatigue, nausea and loss of appetite. The enrollee 
was subsequently diagnosed with hyponatremia and hypokalemia and was admitted as an inpatient to the 
telemetry unit for further evaluation and management. The review has determined that the record showed that 
at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary 
hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided October 18, 2020 to October 20, 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 the full amount for the oral evaluation (D0120), bitewing x-rays 
(D0274), prophylaxis (D1110), and the unspecified preventive service (D1999) provided on September 25, 
2020. 
 
You asked the Plan to pay the full amount for the dental services. You say that you have a $500 benefit for 
dental which should have covered the whole claim. You say that the dentist you use is out of network.  You say 
that you were advised that out of network services would be covered up to the $500 annual limit. You say that 
after your cleaning in March, the plan only paid some of the bill. You say that you appealed and the billed was 
paid in full. You also say that the people who make the initial determination of benefits should be trained better 
so you do not have to appeal every service. The Plan denied your request. The Plan says there is a $500 
maximum coverage limit for dental services each year. The Plan also says that the $500 limit has been 
exhausted. 
 
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 $500 maximum coverage limit for 
dental services has been exhausted.  
 
Date of Service Claim Number Plan Paid 
2/12/2020 200992211200 $152 
3/13/2020 200775524801 $232 
6/12/2020 201673271200 $45 
9/25/2020 202736770200 $71 
TOTAL:  $500 
 
Therefore, we decided that the Plan does not have to pay more for the oral evaluation (D0120), bitewing x-rays 
(D0274), prophylaxis (D1110), and the unspecified preventive service (D1999) provided on September 25, 
2020.  
 
Your complaint about how cases are processed 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by Gates Volunteer 
Ambulance Service on June 3, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 3, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by Gates 
Volunteer Ambulance Service on June 3, 2020.