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

 
We decided that the Plan does not have to pay for periodontal maintenance provided on January 23, 2020. 
 
You asked the Plan to pay for periodontal maintenance. You say that you continued seeing members thinking 
you were in-network. You say that you ask for an exception to reprocess this claim as in-network. The Plan 
denied your request. The Plan says the routine preventive dental services were reprocessed for payment as a 
one-time exception and the periodontal maintenance 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 Plans 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 
periodontal maintenance provided on January 23, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs to participate in rehab. The 
Plan denied your request. The Plan says the enrollee does not require nurse supervision, or daily skilled 
therapy. 
 
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 services. Our physician reviewer 
found that there is no documentation that the enrollee requires skilled nursing services to safely and effectively 
provide medically necessary treatment. Although the enrollee does require skilled therapy services, she does 
not require skilled nursing or therapy services on a daily basis. The enrollee does not require services on an 
inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the clinical information received with the request does not indicate that the portable 
oxygen tanks already provided are not meeting your needs. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
 
 
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 concentrator. Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found you require 
supplemental oxygen at rest and with activity. You have a portable system consisting of E-tanks. You indicate 
that you have difficulty with the tanks when going to appointments outside the home. However, the ordering 
physician does not document why E-tanks do not meet your needs for portable oxygen. Medicare covers 
portable oxygen systems for mobility within the home. Additional oxygen equipment for travel outside the 
home is considered a convenience and is not covered by Medicare. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture - flexible base. 
 
You asked the Plan to pre-approve the dentures. You say that this is needed due to exacerbation of the 
sensitivity with the use of other materials. 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. 
 
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 a 
mandibular partial denture - flexible base.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 4), and the 
drugs or medicaments (D9630) provided from June 10, 2020, to June 17, 2020. 
 
You asked the Plan to pay for the dental services. You say that you went to have a cleaning and x-ray. You say 
that you were not aware that you had periodontal scaling and root planing done. You say that the dental plan 
does not cover this service. You also say that the provider should have told you that this was not covered. The 
Plan denied your request. The Plan says periodontal scaling and root planing is not listed as a covered service. 
The Plan says drugs or medicaments is not listed as a covered service either. 
 
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 
periodontal scaling and root planing (D4341 x 4), and the drugs or medicaments (D9630) provided from June 
10, 2020, to June 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from April 1, 2020, to April 6, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that this copayment is a 
financial hardship for you The Plan denied your request. The Plan says you were charged this copayment 
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 $250 
copayment per day for days 1-7 for inpatient hospital care.  
 
You have been asked to pay a $250 copayment per day, for a total of $1250 (you were in the hospital for 5 
days, so $250 x 5 = $1250). You are not being charged more for using an out-of-network hospital--this is the 
copayment applicable to in-network hospitals. 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 you received from April 1, 2020, to April 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants for the upper arch. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says implants are only covered for lower arch. 
 
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 dental 
implants only for the lower arch. 
 
We looked at the file, and Medicare rules. This request cannot be covered for the upper arch. 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 implants for the upper arch.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that your medical and therapy needs can be met at a lower level of care.The Plan must followMedicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to slow progress, fatigue and confusion. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis 
provided on May 17, 2019, by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that the 
payment should be made to you. The Plan denied your request. The Plan says these services were rendered by 
an OON provider. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation, bitewings, and prophylaxis provided on May 17, 2019, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mattress. 
 
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is a not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns (D2750) for teeth # 28 and 29, and the unspecified 
preventive dental service (D1999) provided from May 18, 2020, to June 16, 2020. 
 
You asked the Plan to pay for the crowns and unspecified preventive service. You say that the Plan approved 
an amount of $3,052 for services dated April 14, 2020, to July 13, 2020. You say that you are now being told 
that the Plan will not pay anything as your maximum benefit has been reached. You say that you cannot afford 
this. You also say that your teeth have been removed and the dentist is holding your dentures until your bill is 
cleared. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 for covered 
dental services. The Plan says the annual maximum has been exceeded. The Plan also says that you were 
advised of the annual maximum benefit during a phone call on March 4, 2020. 
 
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 $1,000 annual maximum benefit 
has been exceeded. The record shows that the Plan paid $149 towards services you received on January 7, 2020 
and $851 towards services you received on June 18, 2020, thus exhausting your annual maximum of $1,000. 
Therefore, we decided that the Plan does not have to pay for crowns (D2750) for teeth # 28 and 29, and the 
unspecified preventive dental service (D1999) provided from May 18, 2020, to June 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on May 26, 2020, and 
May 27, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that the hospital staff gave you these drugs, 
and you were not aware that your benefits would not cover it. The Plan denied your request. The Plan says self-
administered drugs are not covered under Part B of Original Medicare. 
 
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 pay for the self-administered drugs 
provided on May 26, 2020, and May 27, 2020.  
 
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 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 
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 February 17, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER services provided on March 7, 
2020. 
 
You asked the Plan to waive the copayment for the ER services. You say that you were admitted to a different 
hospital so there should be no copayment. The Plan denied your request. The Plan says you were charged this 
copayment 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the ER services. the ER services falls within the Emergency 
Care benefit category. You were not admitted to the same hospital as the ER services. 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 ER services provided on March 7, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve twenty (20) additional excimer laser treatments for plaque 
psoriasis. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation by the dermatologist supports that twenty additional excimer laser 
treatments are medically reasonable and necessary for treatment of the enrollee's plaque psoriasis. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve twenty (20) additional excimer laser treatments for plaque psoriasis.  
 
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 continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee has poor 
coordination due to arthritis. The Plan denied your request. The Plan says the enrollee is not on insulin 
injections. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are only covered 
under certain medical indications.  
 
We looked at the file and Medicare rules. The records do not show that the enrollee is insulin treated, or that 
the insulin treatment requires frequent adjustment based on test results. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone-Acetaminophen for the enrollee. 
 
You asked the Plan to pre-approve this drug. 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. 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 Oxycodone-Acetaminophen 
for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on April 27, 2020. 
 
You asked the Plan to pay for the outpatient mental health 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 
services at issue. 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 outpatient mental health services provided on April 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper and lower denture and extractions 
provided on June 11, 2020. 
 
You asked the Plan to pay for the complete upper and lower denture and extractions. You say that your teeth 
were broken off and they had to be pulled. You say that you had to have a new set of dentures made because 
your partial broke. The Plan denied your request. The Plan says out-of-network dental services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete upper and lower denture and extractions provided on June 11, 2020.