Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on October 1, 2021. 
 
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 services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the laboratory services rendered by the out-of-network (OON) provider on 
October 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with multiple 
power options. 
 
You asked the Plan to pre-approve the Group 2 PWC. You say that it is felt that the PWC is necessary. The 
Plan denied your request. The Plan says the documentation does not support which MRADLs she is not able to 
complete in the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 Group 2 PWC. Our reviewer says 
that the requested PWC is not considered medically reasonable and necessary based on Medicare rules. Our 
physician reviewer found the documentation does not support the need for a power wheelchair. There is no 
indication that the member requires a PWC for mobility-related self-care tasks in the home.  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 Group 2 PWC have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 2 power wheelchair (PWC) with multiple power options.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on January 21, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on January 21, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve primary care services to be rendered by the out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve primary 
care services to be rendered by the out-of-network (OON) provider.
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 SNF care is medically necessary. The Plan denied 
your request. The Plan says your needs are custodial and SNF services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 you have no identifiable skilled nursing needs.  
Although you have identifiable skilled therapy needs, you do not require skilled therapy on a daily basis. You 
do not meet severity of illness or intensity of service criteria for 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 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 pre-approve a pain management office visit to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pain management office visit. You say that the in-network provider was 
not managing your services how you like and would like to see another provider. The Plan denied your request. 
The Plan says there is an approved authorization for an in-network provider and agreed with their primary care 
physician to see that provider. 
 
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 
a pain management office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network 
(OON) provider on April 26, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on April 26, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a special Group 3 power wheelchair options coded as 
follows: E2377 (expandable controller), E2313 (harness for expandable controller), and E2311 (electronic 
connection between the controller and 2 ore more power seating motors.)  
You asked the Plan to pre-approve the power wheelchair options. You say that you require this specific chair 
with these power options to resolve mobility deficits.  You cannot independently perform a functional weight 
shift and you are at risk for developing a pressure ulcer. The Plan denied your request. The Plan says it has 
approved the requested wheelchair, but it has denied the following codes: E2377 (expandable controller), 
E2313 (harness for expandable controller), and E2311 (electronic connection between the controller and 2 ore 
more power seating motors.) The Plan says that your upper limb strength is adequate to be able to control the 
power options using their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are covered when 
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 power wheelchair options. Our 
reviewer says that the requested controller options are not medically necessary. Our physician reviewer found 
the requested accessories are not medically necessary as you do have use of your hands and can operate and 
control the power options using the switches that are included in the basic wheelchair. 
 
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 power wheelchair options have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a special Group 3 power wheelchair options coded as follows: E2377 
(expandable controller), E2313 (harness for expandable controller), and E2311 (electronic connection between 
the controller and 2 ore more power seating motors.)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (36415, 86769, 87536) rendered by 
the out-of-network (OON) provider on November 9, 2021. 
 
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 services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the laboratory services (36415, 86769, 87536) rendered by the out-of-network 
(OON) provider on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that the services provided by the in-
network provider is unsatisfactory and you would like to see an out-of-network provider. The Plan denied your 
request. The Plan says the enrollee's primary care physician did not approve a referral to an out-of-network 
provider and the evaluation was never completed with the in-network provider. Also, the Plan provided a list of 
in-network providers that provide the same quality of care as an out-of-network provider. 
 
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 
a specialist office visit to be provided by an out-of-network (OON) provider.  Your complaint about your experience with this provider 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on December 10, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you have periodontal 
disease, and this exam was just to check the status of the disease. You also say that this exam was not 
comprehensive, but was a preventive exam. The Plan denied your request. The Plan says the comprehensive 
periodontal evaluation is not routine/preventive in nature. 
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. The contract also says that you may pay more for services that are 
received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal 
evaluation (D0180) provided on December 10, 2021 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 four prefabricated abutments (D6056 x4), or pay more 
for the comprehensive oral evaluation (D0150), and reline of a complete maxillary denture (D5750) provided 
on October 19, 2021, and November 16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the prefabricated abutments, and to pay more for the comprehensive oral 
evaluation, and reline of a complete maxillary denture. You say that you only have social security to live on, 
and you would not have taken on this debt if you were not comfortable with your dental plan. The Plan denied 
your request. The Plan says the prefabricated abutments are not a covered benefit under your plan. The Plan 
says that these services were performed by a non-participating provider, and you are responsible for any 
difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The 
Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider 
eligibility. 
 
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, prefabricated abutment (D6056) is not 
among those covered under this benefit. You are responsible for a 50% coinsurance for the comprehensive oral 
evaluation (D0150) and a 75% coinsurance for the reline of a complete maxillary denture (D5750), plus the 
difference between the billed amounts and the allowed amounts because these services were received OON. 
Therefore, we decided that the Plan does not have to pay for the four prefabricated abutments (D6056 x4), or 
pay more for the comprehensive oral evaluation (D0150), and reline of a complete maxillary denture (D5750) 
provided on October 19, 2021, and November 16, 2021 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 periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on September 27, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that your routine 6-month 
dental cleanings have been covered in the past. You also say that each time it was reimbursed. The Plan denied 
your request. The Plan says you had a dental benefit up to the maximum amount of $1,000 to be reimbursed for 
dental services. The Plan also says that you have already received the maximum amount of coverage allowed 
for these types of 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 Plan pays up to $1,000 every year 
for non-Medicare covered preventive and comprehensive dental services combined. The contract says that you 
are responsible for any amount above the dental coverage limit. The record shows that you met the annual 
maximum benefit on April 19, 2021 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on September 27, 2021.
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 a broken back since December 26, 
2021, and you have a hard time without a shower chair. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network ambulance transportation 
provided on September 17, 2021. 
 
You asked the Plan to waive the copayment for out-of-network ambulance transportation. You say that the 
copayment should be waived. The Plan denied your request. The Plan says the copayment amount charged is 
correct. 
 
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 $300 
copayment per one-way trip by ground or air ambulance.  
 
You have been asked to pay $300 for out-of-network ambulance transportation. Ambulance transportation falls 
within the Ambulance Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
out-of-network ambulance transportation provided on September 17, 2021.  
 
The provider is out-of-network with the plan but is participating with Medicare, neither you nor the Plan should 
be responsible for the balance bill of this claim beyond your cost-sharing for this claim.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941), the 
electrical stimulation (G0283), and the office visit (99202) rendered by the out-of-network (OON) provider 
from October 19, 2021, through November 19, 2021. 
 
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 services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the chiropractic manipulative treatment (98941), the electrical stimulation 
(G0283), and the office visit (99202) rendered by the out-of-network (OON) provider from October 19, 2021, 
through November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on July 30, 2021. 
 
You asked the Plan to pay for the dental service. You say that you saw this dentist 3 times. You say that your 
plan did not pay for any of it. You also say that you only want to file for July 30, 2021, and November 5, 2021. 
The Plan denied your request. The Plan says dental services received out of network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on July 30, 2021.