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

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, crown, and core 
buildup services (D2950, D0220, D0140, D2740) provided on November 16, 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 benefit for the requested item or service has 
already been exhausted. Coverage for the crown and core buildup services (D2740, D2950) 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 19, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, crown, 
and core buildup services (D2950, D0220, D0140, D2740) provided on November 16, 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 September 20, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you are asking for the denial to be 
reviewed as you were never told that if you did not go to the emergency room the services would not be paid. 
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 September 20, 2022. 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 September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (electric 
scooter) (K0800). 
 
You asked the Plan to pre-approve an electric scooter. You say that it is very difficult for you to use a manual 
wheelchair because you have arthritis in both shoulders. You also say that you need the scooter badly. The Plan 
denied your request. The Plan says this request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a POV is covered if all of the basic coverage criteria 
(A-C), listed in the Medicare rules section of this letter, have been met and if criteria D-I, listed in the Medicare 
rules section of this letter, are also met. 
 
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 electric scooter. Our reviewer says 
that the power scooter is not medically necessary. Our physician reviewer found you have a medical history of 
knee osteoarthritis and pain that prevents you from ambulating longer distances. This would not be ameliorated 
with the use of a cane or walker. However, there is insufficient clinical documentation indicating why you 
cannot use a manual wheelchair for mobility. Our reviewer found that the physical examination does not 
indicate that you have abnormal range of motion in the upper extremities. You have not trialed a manual 
wheelchair. Our physician reviewer also found that there is no documentation indicating that you can safely 
operate a power scooter and that is home accessible for the requested power mobility device.  
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 electric scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a group 1 standard power operated vehicle (electric scooter) (K0800).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided on June 20, 2022. 
 
You asked the Plan to pay for DME. You say that this should be covered. The Plan denied your request. The 
Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for DME provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298 x 2) purchased on 
July 15, 2021. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though these items may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to issue reimbursement for the 
hearing aids (V5298 x 2) purchased on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that the enrollee should be eligible for SSBCI 
due to medical issues. The Plan denied your request. The Plan says you do not meet the criteria to be eligible 
for SSBCI benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not meet the 
intensive care management criteria listed in the EOC, which is 2 or more inpatient admission in the last 60 
days, or 3 or more emergency room visits in the last 60 days. Therefore, we decided that the Plan does not have 
to pre-approve the SSBCI benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the shingles vaccine (90736) provided on October 
10, 2022. 
 
You asked the Plan to reimburse you for the shingles vaccine. You say that the shingles vaccine is covered 
under the Part D coverage. The Plan denied your request. The Plan says your coverage does not include Part D 
prescription drug coverage. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to reimburse you for the shingles vaccine (90736) 
provided on October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) provided on October 13, 
2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that you have exhausted the allowable benefit 
for this service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that you have exhausted the allowable benefit 
for the oral evaluation provided in this case. The Plan contract states that one oral evaluation is covered per 
calendar year. The Plan provided documentation to our organization that indicates you received an oral 
evaluation previously on October 6, 2022; however, the information does not demonstrate that the Plan paid for 
this service. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we 
decided that the Plan has to pay for the comprehensive oral evaluation (D0150) provided on October 13, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 you want to be admitted to an IRF because you 
would like to regain your independence back. You say that you will not get the required 3 hours of therapy 
needed in a nursing home. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be provided safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on December 12, 2022. 
 
You asked the Plan to pay for the refraction. You say that the refraction was done as a following your cataract 
surgery. The Plan denied your request. The Plan says the service is not a covered benefit. 
 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 performed during a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
exam. The medical records show a diagnosis of dry eye syndrome which makes the eye exam medical in 
nature. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been 
met. Therefore, we decided that the Plan does not have to pay for the refraction provided on December 12, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection with nerve block provided on September 13, 
2022. 
 
You asked the Plan to pay for an injection with nerve block. You say that this was medically necessary and 
should be covered. 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 injection with nerve 
block provided on September 13, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided from 
December 3, 2022, to December 5, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that this was an emergency 
and should be covered. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service 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 visit 
provided from December 3, 2022, to December 5, 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 you want to go to rehab. The Plan denied your 
request. The Plan says the request is not medically necessary, the services you need can be provided safely in 
other settings, for example, 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 while the enrollee may benefit from PT, and OT, the enrollee's rehab needs can be 
provided in a lower intensity and alternate setting such as in an SNF.  
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
October 24, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were not actually 
seen by a provider at the emergency room. 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 $120 
copayment for each emergency department visit. 
 
The medical record shows you received services in the emergency room on October 24, 2022, even though you 
did not see a provider. You have been asked to pay $86.02, which is less than the standard $120 copayment for 
the emergency room visit. This item/service 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 visit provided on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT scan (D0367) provided on November 16, 
2022. 
 
You asked the Plan to pay for dental services. You say that you had to have the CT scan in order to know if you 
needed a root canal or not, so this should be covered. 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. Cone beam CT scan (D0367) 
is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0367 is 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) scan D0367 provided on November 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological testing evaluation services. 
 
You asked the Plan to pre-approve psychological testing evaluation services. You say that the enrollee is being 
seen for psychological evaluation to satisfy a requirement for bariatric surgery. You also say that Minnesota 
Multiphasic Personality Inventory 2 (MMPI-2) testing is administered as a clinical tool to provide for further 
information. The Plan denied your request. The Plan says the documentation does not indicate the presence of 
depressive or anxious symptomology that is active, and no clinical symptoms of a mental health disorder were 
indicated in the request for testing. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is intended to diagnose and characterize 
the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain. 
 
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 psychological testing evaluation 
services. Our reviewer says that neuropsychological testing is not considered reasonable or medically necessary 
for the treatment of this enrollees condition utilizing the information provided. Our physician reviewer found 
this enrollee does not meet the criteria for neuropsychological testing as there is no documentation of physical 
injury present.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychological testing evaluation services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve psychological testing evaluation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your current dentures do not fit and have 
been adjusted multiple times. 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 September 29, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and 
complete denture - mandibular (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on 
October 27, 2022 
 
You asked the Plan to reduce the copayment for an office visit. You say that you say that you never had to pay 
for these services in the past. 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 $40 
copayment for a physician/practitioner specialist in an outpatient location.  
 
You have been asked to pay a $40 copayment for an office visit. This item/service falls within the visit or 
consultation in an outpatient location with a specialist 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 reduce the 
copayment for a specialist office visit provided on October 27, 2022
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 20, 2022.