Persius/hicric huggingface dataset:
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 should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they do not meet the 
clinical requirements to be approved. 
 
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 that the there is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided. The enrollee's needs can 
be met at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 12, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for OTC COVID-19 test purchased on August 11, 2022. 
 
You asked the Plan to pay for OTC COVID-19 test. You say that you would like to be reimbursed for the 
purchase of COVID-19 tests. The Plan denied your request. The Plan says they are not responsible for 
reimbursing OTC COVID-19 test. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022, over-the-counter (OTC) 
COVID-19 tests are covered by Original Medicare, so Medicare Advantage plans are not responsible for 
reimbursement of these test. 
 
We looked at the file and Medicare rules. Based on this information, we decided that since this OTC COVID-
19 test was purchased after April 3, 2022, the Plan is not responsible for reimbursement of it. Please contact the 
Plan for more information about how to request reimbursement from Original Medicare. Therefore, we decided 
that the Plan does not have to pay for OTC COVID-19 test purchased on August 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye surgery provided on September 26, 
2022. 
 
You asked the Plan to waive the copayment for the eye surgery. You say that this was not your fault. 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 $320 
copayment for Medicare-covered outpatient surgery in an outpatient hospital setting. 
 
You have been asked to pay a $320 copayment for the eye surgery. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 eye surgery provided on September 26, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar fusion using Minute Man technique (22612) 
(22840). 
 
You asked the Plan to pre-approve a lumbar fusion using Minute Man technique. You say that this service is 
medically necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 lumbar fusion using Minute Man 
technique. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found this service is considered experimental and more research is needed 
to show safety and efficacy. 
 
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 lumbar fusion using Minute Man technique have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lumbar fusion using Minute Man technique (22612) 
(22840).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233 provided on May 12, 
2022. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee was not in an active hospice episode 
on this date of services. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 2, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
(99233 provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluoride application, prophylaxis, and periodic oral 
evaluation (D0120, D1110, D1206) provided on September 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $1,000 dental benefit maximum 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 requested item or service was exhausted on date of service 05/19/22. Therefore, we 
decided that the Plan does not have to pay for a fluoride application, prophylaxis, and periodic oral evaluation 
(D0120, D1110, D1206) provided on September 14, 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 
(A0998) provided on June 11, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
initially called the advice nurse to see if you should make a doctor's appointment for the following week 
because of your chest pains, and they called 911 while you were on the phone. You also say when the 
emergency medical technician arrived, they took your vital signs and you were told they were fine, so you 
decided not to be transported to the emergency room. The Plan denied your request. The Plan says this service 
is not covered under your contract under any normal circumstances. 
 
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 June 11, 2022. The record shows that you also 
signed an against medical advice (AMA) form as well as a refusal of transport. 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 (A0998) provided on June 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DNA gene analysis provided on October 12, 2021. 
 
You asked the Plan to pay for DNA gene analysis. You say that the service was 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 DNA gene analysis 
provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 dental services provided on August 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care and wound care provided on 
August 30, 2022. 
 
You asked the Plan to pay for the subsequent nursing care and wound care. You say that the 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 the subsequent nursing 
care and wound care provided on August 30, 2022.
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 enrollee requires assistance to perform her 
activities of daily living (ADLs) and needs immediate admission for inpatient rehabilitation to regain her prior 
level of function. The Plan denied your request. The Plan says the IRF care is not medically necessary, and the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility. 
 
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 respiratory failure, pneumonia, and heart failure. The 
enrollee's medical problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. 
 
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 core buildup, retainer crown, and pontic dental services 
(D2950, D6740, D6245) provided on September 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $1,000 dental benefit maximum allowance 
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 requested item or service was exhausted on date of service 09/22/2022. Therefore, 
we decided that the Plan does not have to pay for core buildup, retainer crown, and pontic dental services 
(D2950, D6740, D6245) provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D Oral/facial photographic images obtained intraorally or 
extra orally (D0350) Tooth #1 and 32 provided on October 4, 2022. 
 
You asked the Plan to pay for dental services. You say that you feel the x-ray was needed in order to help with 
your care. 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. 2D Oral/facial photographic 
images obtained intraorally or extra orally (D0350) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0350 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 2D Oral/facial 
photographic images obtained intraorally or extra orally (D0350) Tooth #1 and 32 provided on October 4, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft on tooth #24 (D7953) and a 
complete mandibular overdenture (D5865). 
 
You asked the Plan to pre-approve a replacement graft and an overdenture. You say that you disagree with the 
denial of dental services. The Plan denied your request. The Plan says a bone replacement graft (D7953) is not 
covered by the enrollee's dental benefits. The Plan also says that the enrollee's benefit for a complete 
mandibular overdenture (D5865) 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, a bone replacement graft is not among 
those covered under this benefit. The record shows the enrollees benefit for a complete mandibular 
overdenture was exhausted on date of service December 28, 2020. Therefore, we decided that the Plan does not 
have to pre-approve a bone replacement graft on tooth #24 (D7953) and a complete mandibular overdenture 
(D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010), bone grafts (D0470), 
diagnostic casts (D0367) and a cone beam (C0367). 
 
You asked the Plan to pre-approve an endosteal implant (D6010), bone grafts (D0470), diagnostic casts 
(D0367) and a cone beam (C0367). You say that you are appealing this denial. The Plan denied your request. 
The Plan says these services are 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 pre-approve an 
endosteal implant (D6010), bone grafts (D0470), diagnostic casts (D0367) and a cone beam (C0367).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bite analysis (D9950), local anesthesia (D9215), and a 
partial mandibular denture (D5214). 
 
You asked the Plan to pre-approve bite analysis, anesthesia, and a denture. You say that the requested dental 
services are medically necessary. The Plan denied your request. The Plan says that bite analysis (D9950), local 
anesthesia (D9215), and a partial mandibular denture (D5214) are not covered by your 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 bite 
analysis (D9950), local anesthesia (D9215), and a partial mandibular denture (D5214).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of elbow (73070) provided on June 25, 2022. 
 
You asked the Plan to pay for the x-ray. You say that the enrollee revoked their hospice election prior to the 
date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 23, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the x-ray of elbow (73070) 
provided on June 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 18, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab services. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says There was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
 
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 lab services provided on July 18, 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 the eyeglass lenses and frames purchased on August 2, 2022, 
from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eyeglass lenses and frames. You say that the provider you were treated by is 
an approved vendor. You also say that you are entitled to $300 for eyeglasses during the 2022 benefit year. The 
Plan denied your request. The Plan says this eyewear was purchased from an OON provider. 
 
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 these services when they are provided by a contracted provider. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you purchased this eyewear from 
a non-contracted provider. Based on this information, we decided that the Plan's rules for coverage of the 
eyeglass lenses and frames have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyeglass lenses and frames purchased on August 2, 2022, from an out-of-network (OON) provider.