Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on September 20, 
2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that these services were medically 
neccesary. 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 domiciliary or rest 
home visit provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377) 
and a padded lap belt (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you are requesting reconsideration for 
this wheelchair based on medical necessity being proven for the enrollee. The Plan denied your request. The 
Plan says although there are three approved power options on this wheelchair (tilt, recline and elevating leg 
rests), there is not a medical need to control these power options through the joystick. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found according to Medicare, a power mobility device is medically necessary if an enrollee 
has a mobility limitation that significantly impairs his ability to participate in one or more mobility-related 
activities of daily living. The mobility limitation cannot be sufficiently and safely resolved by the use of a fitted 
cane or walker, or the enrollee does not have sufficient upper extremity function to self-propel an optimally 
configured manual wheelchair. Additionally, if any POV or PWC is only for use outside the home, it is denied 
as noncovered. The enrollee must also have the mental and physical capabilities to safely operate the power 
wheelchair and the home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the PWC. An expandable controller is an electronic system that is capable of accommodating one 
or more additional features and can operate 3 or more powered seating options. In this case, the enrollee has 
been authorized to have a power wheelchair. The requested electrical accessories are not medically necessary 
as the enrollee does have use of the upper extremity and can operate and control the power options using the 
switches that are included in the basic wheelchair. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors (E2311), a harness (E2313), an expandable controller (E2377) and a padded lap belt 
(K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 02, 2022. 
 
You asked the Plan to pay for an office visit. You say that you believe no prior authorization was needed to see 
a Virginia provider. 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 November 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740) provided on December 
13, 2022. 
 
You asked the Plan to pay for the crown. You say that one of your front teeth broke off and was replaced by the 
dental practice. You also say that you were informed that only a small portion  would be covered. The Plan 
denied your request. The Plan says this service is 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 pay for a crown - 
porcelain/ceramic (D2740) provided on December 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of heart without contrast 
with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve CT of heart without contrast with quantitative evaluation of coronary 
calcium. You say that the service is medically necessary. The Plan denied your request. The Plan says this 
service is not covered for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CT of heart without contrast with 
quantitative evaluation of coronary calcium. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found coronary CT calcium scoring in an asymptomatic individual with severe statin 
intolerance does not affect the primary prevention method or affect the outcome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT of heart without contrast with quantitative evaluation of coronary calcium 
have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography 
(CT) of heart without contrast with quantitative evaluation of coronary calcium (75571).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - two radiographic images (D0272) provided on 
November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the procedure was performed to diagnose a pain 
in your jaw which was not present in your routine check-ups. 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 requested item or service was exhausted on date of service August 3, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewings - two radiographic images (D0272) 
provided on November 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on July 12, 
2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to 
pay a copayment for each trip on this date. 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 $270 
copayment for each one-way Medicare-covered ambulance trip.  
 
According to the EOC, your copayment applies for each one-way trip. You have been asked to pay a $270 
copayment for the ambulance services. This item/service falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for ambulance services provided on July 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance service. 
 You asked the Plan to pay for the air ambulance service. You say that the medical records provided support the 
need for the requested air ambulance transport. The Plan denied your request. The Plan says the air ambulance 
transport was not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 pay for the air ambulance service. Our reviewer says 
that the air transport service was not medically necessary. Our physician reviewer found the enrollee is noted to 
have suffered a fall with suspected humerus fracture. The enrollee appears to have been hemodynamically 
stable and neurologically intact. While further evaluation was necessary, the enrollee could have been 
transported by ground ambulance without an expected decline in the enrollees condition. The use of air 
ambulance was not medically necessary or reasonable. 
 
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 air ambulance service have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance service.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on August 
06, 2022, to August 31, 2022. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that the records attached support 
the services provided. 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 subsequent nursing 
facility care visit provided on August 06, 2022, to August 31, 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 requires intensive inpatient rehabilitation 
with daily physician management and intensive therapies to optimize their mobility. You say that the enrollee's 
needs cannot be safely met at a skilled nursing facility or home health as they require direct physician 
supervision and management. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and the enrollee's needs can be met at an alternate level of care. 
 
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 enrollees 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: 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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says criteria for admission to the LTACH have 
not been met. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. There are no services available at the LTACH that 
the enrollee requires that are not available at the health care setting being offered by the Plan. The Plan has 
approved ongoing care in the current acute care setting. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a localized delivery of antimicrobial agents and periodontal 
maintenance (D4381, D4910) provided on July 19, 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 services denied correctly as they do not fall 
within 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 pay for a 
localized delivery of antimicrobial agents and periodontal maintenance (D4381, D4910) provided on July 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral exam provided on October 19, 2022. 
 
You asked the Plan to pay for the exam. You say that you don't know why the claim was denied as you had 
routine dental as part of your 2022 insurance. You say you do not feel you owe this. 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 requested item or service was exhausted on date of service May 3, 2022. Therefore, 
we decided that the Plan does not have to pay for an oral exam provided on October 19, 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 monitoring, management of 
pain, wound care, nutritional consult, aggressive physical and occupational therapy, and close monitoring with 
daily physician oversight. The Plan denied your request. The Plan says the enrollee records does not meet all 
the required criteria for admission to an Inpatient Rehabilitation Facility. Skilled therapies at home or at a 
skilled nursing facility may be approved upon request. 
 
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 has advanced chronic illness and a very deconditioned state and cannot 
participate in or reasonably benefit from intensive rehabilitation services. The IRF is not a medical step-down 
unit for continuation of hospital 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 coded as 87641, 87581, 87486, 
87631, 87653, 87798, 87541, 87532, 87498 and 87496 provided on October 11, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that your group is an independent laboratory and 
performed the test of the enrollee as per the notes of the ordering physician. Please consider this claim as an emergency service and reimburse you according to the Plan's fee schedule. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 the laboratory services coded as 87641, 87581, 
87486, 87631, 87653, 87798, 87541, 87532, 87498 and 87496 provided on October 11, 2022, by an out-of-
network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on 
November 29, 2022. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that the facility is responsible for 
obtaining prior 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 a subsequent nursing 
facility care visit provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 
12, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were told the 
physician was an in-network provider. 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 $65 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $65 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 a specialist office visit provided on October 12, 2022.