Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an assisted living facility visit provided on November 14, 
2022. 
 
You asked the Plan to pay for an assisted living facility visit. You say that the provider was not responsible for 
obtaining authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an assisted living facility 
visit provided on November 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit services provided on October 12, 2022, 
to October 26, 2022. 
 
You asked the Plan to pay for psychotherapy visit services. You say that this should be covered, you were 
seeing this provider during a hospital stay, then were referred to them after your discharge. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy visit 
services provided on October 12, 2022, to October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture services (97810) and the 
office visits (99204, 99213) rendered by an out-of-network (OON) provider from November 22, 2022, through 
December 22, 2022. 
 
You asked the Plan to issue reimbursement 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 issue reimbursement 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 issue reimbursement for these services. Therefore, we 
decided that the Plan does not have to issue reimbursement for the acupuncture services (97810) and the office 
visits (99204, 99213) rendered by an out-of-network (OON) provider from November 22, 2022, through 
December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit and related services provided on December 28, 
2022. 
 
You asked the Plan to pay for a home visit and related services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit and related 
services provided on December 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on October 28, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that these items do not require separate 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on October 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection administration provided on 
October 27, 2022. 
 
You asked the Plan to waive the copayment for the injection administration. You say that you were not advised 
of the copayment until after the procedure. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $350 
copayment for in-network outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $350 copayment for the injection administration. This item/service falls within the in-network outpatient surgery, including services provided at hospital outpatient facilities 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 the injection administration provided on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 27, 2022. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on December 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 7, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this should 
be covered as it was just a plain pick-up. You also say that you didn't know that there was no coverage for 
refusing an ambulance ride. 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 January 7, 2023. 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 response and treatment with no 
transport provided on January 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental service. You say that you need the guard to keep from ruining all 
your lower teeth as they are wearing down badly. You say you cannot afford to buy the guard. The Plan denied 
your request. The Plan says this service is not a covered expense under your dental plan. 
 
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 an 
occlusal guard (D9944).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70546 billed for date of service December 
12, 2022. 
 You asked the Plan to pay for procedure code 70546. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70546 is bundled into payment for code 
70553. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70546 
is a column II code to column I code 70553. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70546 billed for date of service December 12, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subcutaneous tissue debridement provided on December 29, 
2022. 
 
You asked the Plan to pay for subcutaneous tissue debridement. You say that this service is supported in the 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subcutaneous tissue 
debridement provided on December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and core buildup for tooth number 31 provided on 
December 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that crowns are covered benefit in 2023. You were 
billed for the crown in 2022 but received the crown in 2023. The Plan denied your request. The Plan says these 
services are not covered by the Plan's 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 pay for the crown 
and core buildup for tooth number 31 provided on December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120), and 
maxillary partial denture  resin base (including, retentive/clasping materials, rests, and teeth) (D5211). 
 
You asked the Plan to pre-approve the complete denture - mandibular, and maxillary partial denture  resin 
base. The Plan denied your request. The Plan says these services are not covered under the benefit package. 
 
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 a 
complete denture - mandibular (D5120), and maxillary partial denture  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5211).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3000). 
 
You asked the Plan to pre-approve the foot orthotics. You say that the need for the foot insert is based on 
medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain fused to predominantly base metal 
(D2751) Tooth #20. 
 
You asked the Plan to pre-approve the dental services. You say that the requested service is needed in order to 
relieve the pain so you can eat and sleep. The Plan denied your request. The Plan says your benefit for the 
requested item or service 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. This benefit includes the 
requested crown - porcelain fused to predominantly base metal (D2751) but is limited to treating badly broken-
down teeth, 1 cap (or crown) per year, one crown in 5 years per tooth. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your Plan approved crown - porcelain fused to predominantly base metal (D2751) Tooth #19 on April 5, 
2023. Therefore, these benefits were exhausted as of April 5, 2023. Therefore, we decided that the Plan does 
not have to pre-approve crown - porcelain fused to predominantly base metal (D2751) Tooth #20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265) Tooth #5, 9, 14, 20 and 29. 
 
You asked the Plan to pre-approve dental services. You say that you need the requested service because it is 
hard to eat. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Biologic materials to aid in 
soft and osseous tissue regeneration, per site (D4265) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D4265 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve biologic 
materials to aid in soft and osseous tissue regeneration, per site (D4265) Tooth #5, 9, 14, 20 and 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056 x 2) and abutment 
supported crowns (D6058 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the Plan misrepresented their dental 
benefits to get your enrollment. The Plan denied your request. The Plan says these services are not covered by 
the Plan's 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 
prefabricated abutments (D6056 x 2) and abutment supported crowns (D6058 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751). 
 
You asked the Plan to pre-approve a crown. You say that this dental code (D2751) was covered last year, and 
your dentist does not provide crowns that are listed as covered dental codes by the Plan. The Plan denied your 
request. The Plan says this service is not covered under your dental plan. 
 
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 a 
crown (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0380) and a consultation (D9310) provided 
on January 24, 2023. 
 You asked the Plan to pay for the dental services. You say that you are submitting the bill for reimbursement. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
cone beam and consultation are not covered by the Plan. 
 
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 a cone 
beam (D0380) and a consultation (D9310) provided on January 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tobramycin. 
 
You asked the Plan to pre-approve Tobramycin. You say that the requested Tobramycin is medically necessary. 
The Plan denied your request. The Plan says the requested Tobramycin is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Tobramycin. Our reviewer says that the 
requested Tobramycin is not medically necessary. Our physician reviewer found the requested use of 
Tobramycin is not Food and Drug Administration-approved for the enrollee's diagnosis of chronic laryngitis 
and tracheitis. The requested use of Tobramycin for the treatment of chronic laryngitis and tracheitis is not 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical 
journal. The requested use of Tobramycin for the treatment of chronic laryngitis and tracheitis is not indicated, supported, or recommended in any of the compendia. The requested use of Tobramycin for the treatment of 
chronic laryngitis and tracheitis does not meet Medicare criteria for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tobramycin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Tobramycin.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-periapical x-rays (D0220 and D0230) and bitewing 
x-rays (D0274) provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration stating you 
asked the Plan not to pay for the dental services at the appointment you walked out on. You say you asked the 
Plan to pay for the services you received elsewhere. The Plan denied your request. The Plan says your benefit 
for the requested item or service 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 intraoral-periapical x-rays and bitewing x-rays was exhausted on date of service 
September 29, 2022. Therefore, we decided that the Plan does not have to pay for intraoral-periapical x-rays 
(D0220 and D0230) and bitewing x-rays (D0274) provided on December 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the spinal injection provided on November 
03, 2022. 
 
You asked the Plan to waive the copayment for the spinal injection. You say that you have never had to pay so 
much for this procedure. The Plan denied your request. The Plan says this cost sharing was charged 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 for in-network outpatient surgery. 
 
You have been asked to pay a $250 copayment for the spinal injection. This item/service falls within the in-
network outpatient surgery 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 the spinal 
injection provided on November 03, 2022.