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

 
We decided that the Plan does not have to provide an additional 24 routine transportation trips for 2022. 
 
You asked the Plan to provide additional routine transportation. You say that you cannot drive, and this 
transportation is necessary for you to get to your appointments. The Plan denied your request. The Plan says 
your benefit covers up to 24 one-way trips per year. Additional trips are not a covered 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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 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 provide an additional 24 routine transportation trips for 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of impacted tooth #17 (D7240) and 
therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve the dental services. You say that you need to have a wisdom tooth out. The 
Plan denied your request. The Plan says removal of an impacted tooth (D7240) and therapeutic parenteral drugs 
(D9612) are not covered by your routine dental 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, 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 the 
removal of impacted tooth #17 (D7240) and therapeutic parenteral drugs (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
complete x-ray series (D0210) provided on April 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would not have had the services done if you 
knew you were going to be charged for them. The Plan denied your request. The Plan says your benefit for the 
requested items or services has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service April 8, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and 
intraoral complete x-ray series (D0210) provided on April 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF criteria per CMS guidelines 
with a diagnosis of critical illness myopathy. You say that you can manage her current medical needs in the 
unit while she is receiving rehab to optimize physical function. The Plan denied your request. The Plan says 
services can safely be provided in other settings. 
 
  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on April 1, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you went to an approved provider for cataract 
surgery, and followed up with a refraction. You also say that it should be covered. The Plan denied your 
request. The Plan says this eye refraction was performed with a medical diagnosis. 
 
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 eye refractions during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that you were see for the diagnosis of glare, 
decreased vision, and tearing. Based on this information, we decided that the Plan's rules for coverage of the 
eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye 
refraction provided on April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on April 6, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that the information sent to you states that eye 
refractions are covered, and this was confirmed with a Plan representative. The Plan denied your request. The 
Plan says the exam you received was a medical vision check. The Plan also says that eye refractions are only 
covered by the Plan if performed by a participating provider and performed as a routine screening. 
 
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 eye refractions during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that this refraction was performed during a diabetic 
eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have 
not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided 
on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), 
prophylaxis - adult (D1110), and periodic oral evaluation - established patient (D0120) provided April 27, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that this is a respected dentist, and you would like to 
be able to continue to see him. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the bitewings - four radiographic images (D0274), prophylaxis - adult (D1110), and periodic oral 
evaluation - established patient (D0120) provided April 27, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) and a periodic oral 
evaluation (D0120) provided on February 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that your dental plan offers out-of-network 
coverage. The Plan denied your request. The Plan says if your plan offers out-of-network dental coverage and 
you see an out-of-network dentist you might be billed more, even for services listed as $0 copayment. 
 
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. 
 
If your plan offers out-of-network dental coverage and you see an out-of-network dentist you might be billed 
more, even for services listed as $0 copayment. 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 pay for periodontal 
maintenance (D4910) and a periodic oral evaluation (D0120) provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99231) provided on February 4, 
2022. 
  You asked the Plan to pay for subsequent hospital care (99231). You say that the claim denied as a duplicate in 
error and the attached records support that this procedure was performed by the provider. You say that the 
claim should be reviewed and reimbursed according to the contract. The Plan denied your request. The Plan 
says this service is bundled as part of the global surgical fee. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for procedures 
includes payment for certain services related to the surgery when furnished by the physician who performs the 
surgery. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of subsequent hospital care (99231) have not been met. Specifically, CPT code 99231 was billed 
within 90 days by the same provider and was not billed with a modifier to indicate that this was unrelated to the 
surgery. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99231) 
provided on February 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve behavioral health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve behavioral health services to be provided by an OON provider. You say that 
you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the requested 
services are neither emergent nor urgent to seek out-of-network care. The Plans says there are in-network 
behavioral health specialists available to you that you have not seen that can provide the services you are 
requesting. 
 
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 
behavioral health services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of IRF admission. The 
Plan denied your request. The Plan says based on Medicare guidelines and the information we have about your 
condition you do not meet the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found you were admitted to an acute hospital on 6/21/22 with acute respiratory failure, 
symptomatic bradycardia, aspiration PNA, encephalopathy, acute on chronic renal failure requiring HD briefly 
and urinary retention. Has dysphagia, intubated briefly, and you also had a NG tube feeding. You are medically 
stable and left with debility. Comorbid conditions are all stable. There are no complex nursing or rehabilitation 
needs. While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 
 
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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a group 2 power wheelchair. 
 
You asked the Plan to pre-approve the requested services. You say that you never received a wheelchair in 
2020. The Plan denied your request. The Plan says that you do not meet the statutory requirement for a 
replacement wheelchair. 
 
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. 
 
We looked at the file and the rules. The records include a mobility evaluation and home assessment both in 
October 2021. These records do not indicate that the enrollee has a current working power wheelchair. The 
Plan does state that the enrollee received a wheelchair in January of 2020. However, there is no documentation 
showing proof of delivery. There is no documentation of a specific date when the previous wheelchair was 
provided. The case file does not show that the Plan requested information from the durable medical provider to 
verify that a wheelchair was previously provided. The Plan has not made reasonable and diligent efforts to 
gather and forward to us information regarding their decision to deny your request.  Therefore, we decided that 
the Plan has to pre-approve a group 2 power wheelchair.  
 
 
 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the long-term acute care hospital (LTACH) services 
you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the patient requires that are not already 
available and covered at the current facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have no leg on your right and you need learning 
and help to move towards recovery. The Plan denied your request. The Plan says based on Medicare guidelines 
and the information we have about your condition you don't meet the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found you were admitted for gangrene, peripheral artery disease and a below the knee 
amputation. Medicare problems are stable. There are no complex nursing or rehabilitation needs. While you 
have a need for physical or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 
 
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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient medical services provided from March 10, 2022, through 
March 11, 2022. 
 
You asked the Plan to pay for the inpatient medical services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says that prior authorization 
was not obtained for these services rendered by an OON provider. 
 
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 Plans contract states that prior authorization is not required when you get care from out-of-
network providers. 
 
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 says there was no authorization for out-of-network services. The 
Evidence of Coverage clearly states that prior authorization is not required for out-of-network services. This 
means that the Plan has not provided a valid reason for denying payment of the medical services at issue. It is 
the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the inpatient 
medical services provided from March 10, 2022, through March 11, 2022.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit and inpatient hospital care 
provided from December 11, 2021, to December 15, 2021. 
 
You asked the Plan to waive the copayment for ER visit and inpatient hospital care. You say that the 
copayment applied is incorrect. The Plan denied your request. The Plan says the copayments applied are 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay $90 copayment per visit to the ER and $210 per day for days 1 through 6 of inpatient hospital care.  
 
 The enrollee has been asked to pay a total of $930 copayment for the ER visit and inpatient hospital care. ER 
visits fall within the Emergency Care benefit category.  The inpatient hospital care falls within the Inpatient 
Hospital Care benefit category. This means that the enrollee has been asked to pay the correct amount based on 
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ER visit 
and inpatient hospital care provided from December 11, 2021, to December 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial of IRF admission. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria and it is not medically 
necessary. A lower level of care might be appropriate. Skilled nursing facility level of care was offered on 
7/26/2022. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found the enrollee was admitted for hypotension, kidney injury, and anemia. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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-approve acute inpatient rehabilitation facility (IRF) admission and services.