Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2310). 
 
You asked the Plan to pre-approve an electronic connection. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee can control power tilt function through the switch and this 
electronic connection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the requested electronic connection is subject to the 
coverage criteria listed 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 an electronic connection. Our reviewer 
says that the requested device is not medically reasonable and necessary. Our physician reviewer found the 
patient is a 72 year old male with obesity and chronic obstructive pulmonary disease, repeated falls, and 
reduced mobility who was approved for a Group 2 wheelchair with power tilt. Coverage criteria for the E2310 
have not been met per Local Coverage Article: Power Mobility Devices - Policy Article (A52498). The 
patient's upper extremity strength and function with independence in eating support that this patient can control 
any power options on the approved wheelchair with their own individual switches. The E2310 exceeds the 
patient's medical need. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2310).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional six (6) physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you need additional physical therapy. The 
Plan denied your request. The Plan says they have agreed to cover 6 of the additional 12 visits requested; 
however, the remaining 6 visits are not medically necessary. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested 6 therapy visits are generally not 
accepted as specific and effective therapy for your condition beyond what was approved by the plan. You have 
had extensive prior therapy, and the documentation does not reveal that you require the unique skills of a 
professional therapist to safely and effectively provide treatment, or that the services can only be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. You were approved for 
additional therapy to transition to an independent home exercise program. The requested services are not part 
of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an additional six (6) physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D6740 and D6245) received on December 9, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. 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 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 dental 
services (D6740 and D6245) received on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210). 
 
You asked the Plan to pre-approve surgical extractions. You say that these services are necessary. The Plan 
denied your request. The Plan says extractions are not included in the Plan's dental 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 
surgical extractions (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup (D2950) provided by an out-of-network 
provider on December 7, 2021. 
 
You asked the Plan to pay for a core buildup. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says services provided by an out-of-network dentist 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 Plan's coverage rules apply in this case. The Plan covers a core buildup 
when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a core buildup have not been met. Therefore, we decided that the Plan does not have to pay for a 
core buildup (D2950) provided by an out-of-network provider on December 7, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
October 28, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you had no choice but to go to the 
ER since your PCP was unavailable. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $110 
copayment for each emergency room visit.  
 
You have been asked to pay a $110 copayment for the ER visit. The ER visit falls within the Emergency Care 
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 an emergency room (ER) visit 
provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0367) provided on December 9, 2021. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that this service was 
necessary. The Plan denied your request. The Plan says this service is not a covered benefit 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 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 cone 
beam computed tomography (CT) capture and interpretation (D0367) provided on December 9, 2021.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 while you may benefit from physical and occupational therapy, your rehabilitation 
can be safely provided at a lower intensity and alternate setting such as in a skilled nursing facility. Documentation does not support the necessity for admission to an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinical crown lengthening (D4249) provided on October 
26, 2021. 
 
You asked the Plan to pay for the dental service. You say that it was your understanding that periodontal 
services were covered. You say that your dentist referred to the service you needed as a "gingivectomy". You 
say that you were advised by a plan representative that gingivectomy is listed as covered, but clinical crown 
lengthening is not. You also say that at least partial payment should be made. The Plan denied your request. 
The Plan says clinical crown lengthening is not listed as a covered service. 
 
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 clinical crown lengthening is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
clinical crown lengthening (D4249) provided on October 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (93306). 
 
You asked the Plan to pre-approve a transthoracic echocardiogram. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a transthoracic echocardiogram. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no supportive evidence for the medical necessity of a transthoracic 
echocardiogram in this enrollees clinical management. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a transthoracic echocardiogram have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a transthoracic echocardiogram (93306).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case.  Our physician reviewer found the review indicates that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that your necessary hospital care would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the subcutaneous tissue debridement 
(11042) and the debridement of muscle and/or fascia (11043) provided from October 4, 2021, through 
November 8, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $295 copayment for Medicare-covered surgery or 
other services provided to you at an outpatient hospital, including but not limited to hospital or other facility 
charges and physician or surgical charges.  
 
You have been asked to pay $1,180 ($295 copayment x 4) for the Medicare-covered surgery provided at an 
outpatient hospital. 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 copayments for the subcutaneous tissue 
debridement (11042) and the debridement of muscle and/or fascia (11043) provided from October 4, 2021, 
through November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for a specialist office visit, 
fluoroscopic imaging guidance, and a triamcinolone acetonide injection provided on September 30, 2021. 
 You asked the Plan to waive the copayments and coinsurance for the specialist office visit, fluoroscopic 
imaging guidance, and injection. You say that the only copayment should be the $35 outlined in the benefits. 
The Plan denied your request. The Plan says the correct copayments and coinsurance were applied. 
 
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 $35 
copayment for services obtained from a specialist, including surgical services furnished in a physician's office. 
 
Your contract with the Plan also clearly says that you must pay a $110 copayment for radiological diagnostic 
services, not including X-rays. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Part B drug, 
including pain management drugs. 
 
You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also 
been asked to pay $74.77 for the fluoroscopic imaging guidance, which is less than the $110 copayment. The 
fluoroscopic imaging guidance falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. You have also been asked to pay $4.13 for the injection, which is 20% of the 
allowed amount ($20.64 allowed amount x 20% coinsurance = $4.13). The injection falls within the Medicare 
Part B Prescription Drugs benefit category. The total for the visit is $113.90. 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 copayments and coinsurance for a specialist office visit, fluoroscopic imaging guidance, and a 
triamcinolone acetonide injection provided on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on 
December 14, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment per visit for a specialist office visit.  
 
You have been asked to pay a $50 copayment for the specialist office visit provided. 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 office visit (99214) provided on  
December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on October 20, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for chiropractic care. You say that you had not realized the referral had expired The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic care provided on October 20, 2021 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve this service. 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 service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve chiropractic 
care to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete mandibular denture (D5120) provided on 
December 3, 2021. 
 
You asked the Plan to pay for the complete mandibular denture. You say that you are on a fixed income and 
cannot afford the dentures out of pocket. You also say that the dentures were necessary for your health and 
care. The Plan denied your request. The Plan says this claim processed correctly. The Plan also says that your 
maximum allowed for the quarterly maximum has been met. 
 
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 offers up to a $250.00 
allowance for covered comprehensive dental services every quarter. The contract says that after plan paid 
benefits for comprehensive dental services, you are responsible for the remaining costs. The record shows that 
you became eligible on April 1, 2021, allowing for three quarters of your benefits for 2021 in the amount of 
$750.00 for the year. On August 18, 2021, you had extractions which the Plan issued a payment amount of 
$370.00, which used $370.00 of your dental allowance. On December 03, 2021, you received a maxillary 
immediate denture (D5130) and complete mandibular denture (D5120). The remaining $380.00 was assessed to 
code (D5130), exhausting your comprehensive dental allowance. Therefore, we decided that the Plan does not 
have to pay for the complete mandibular denture (D5120) provided on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on August 25, 2021. 
 
You asked the Plan to pay for the core buildup. You say that you needed a crown and the dentist had to do a 
core buildup before the crown could be attached to your tooth. 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. 
 
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 core 
buildup, including any pins when required (D2950) provided on August 25, 2021.