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 (D0140) provided by a participating 
provider on July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not feel like you should be responsible 
for 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 March 23, 2022, and July 
11, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided by a participating provider on July 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional physical therapy (PT) sessions (97164). 
 
You asked the Plan to pre-approve 7 additional PT sessions. You say that the enrollee needs additional PT. The 
Plan denied your request. The Plan says additional PT 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 7 additional PT sessions. 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 therapy generally is not 
accepted as specific and effective therapy for the enrollees condition beyond what was approved by the Plan. 
The enrollee has had prior therapy and the documentation does not reveal that the enrollee requires the unique 
skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. 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 the enrollee's current 
condition or to prevent or slow further deterioration. The enrollee has been instructed in a home exercise 
program.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 7 additional PT sessions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 7 additional physical therapy (PT) sessions (97164).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional intraoral imaging (D0230) provided by a 
participating provider on July 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that these images were necessary. 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 July 27, 2022. Three 
intraoral imaging were rendered. One intraoral image was paid. The other two intraoral imaging have been 
correctly denied. Therefore, we decided that the Plan does not have to pay for additional intraoral imaging 
(D0230) provided by a participating provider on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 6, 2022, to July 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says there is no coverage for sales tax when charged with 
services that are not covered. 
 
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 dental 
services on July 6, 2022, to July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the facet joint injections (64491, 64490).
You asked the Plan to pre-approve the facet joint injections. You say that the service is medically necessary.
The Plan denied your request. The Plan says the service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there
must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief
being consistent with the agent used).
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 facet joint injections. Our reviewer
says that the service is not medically necessary. Our physician reviewer found the enrollee did not achieve 80%
pain relief after the first diagnostic facet join procedure.
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 facet joint injections have not been met. Specifically, the enrollee did not
achieve 80% pain relief after the first diagnostic facet join procedure. Therefore, we decided that the Plan does
not have to pre-approve the facet joint injections (64491, 64490).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the lightweight wheelchair billed for November 8, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the capped 
rental period has been exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 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. 
 
We looked at the file and the rules. In this case, the Plan has not provided documentation that the enrollee 
exercised the purchase option for the wheelchair at issue. The Plan has not made reasonable and diligent efforts 
to gather and forward to us information regarding their decision to deny your request. Therefore, we decided 
that the Plan has to pay for the lightweight wheelchair billed for November 8, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 9, 
2021. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.

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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support 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 the dental services on June 27, 2022, to June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 the dental services on June 27, 2022, to June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee-shin system stance flexion. 
 
You asked the Plan to pre-approve knee-shin system stance flexion. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested part is unbundled from the approved knee 
and cannot be requested separately. 
 
The Plan must follow Medicare rules. Medicare rules say that additions to protheses are only covered for 
certain indications.  
 
We looked at the file and Medicare rules. The requested stance control in code L5845 is included in the 
approved knee unit identified with code L5814. Based on this information, we decided that Medicare rules for 
coverage of knee-shin system stance flexion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee-shin system stance flexion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tie-down brackets for wheelchair transportation 
(K0108). 
 
You asked the Plan to pre-approve tie-down brackets for wheelchair transportation. You say that this is 
medically necessary. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve tie-down brackets for wheelchair transportation (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided by a participating provider 
on July 21, 2022. 
 
You asked the Plan to pay for a core build-up. You say that you would like these charges covered. The Plan 
denied your request. The Plan says D2950 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 a core 
build-up (D2950) provided by a participating provider on July 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says there are not enough studies to show that the Vertiflex device will improve the health of people with the enrollee's medical condition.

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 the Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy before coverage can be approved.

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation shows that the enrollee had a clinical change in status thus would 
be expected to require skilled nursing however there is no documented recommendation for frequency. There 
are no therapy notes available thus based on available clinical documentation, daily skilled services on an 
inpatient basis in a SNF is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), intraoral - complete series of radiographic images (D0210), and 2D oral/facial photographic image 
obtained intra-orally or extra-orally (D0350) provided on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware nor informed that previous 
claims would affect the new claims when you enrolled in the Plan April, 2022. The Plan denied your request. 
The Plan says the denial is correct, because these services are not covered by the Plans dental benefits or they 
are covered but the coverage benefit has 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 items or services was exhausted on date of service August 27, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150), intraoral - complete series of radiographic images (D0210), and 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350) provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service 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 the dental 
services on June 29, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on May 29, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that the nurse from urgent care sent you here 
so it 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 $60 
copayment for Emergency care. 
 
You have been asked to pay a $60 copayment for ER 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 ER visit provided on May 29, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial lower denture (D5214) provided on July 12, 2022. 
 
You asked the Plan to pay for the dental service. You say that the provider told you that the insurance would 
cover the denture and you would like the Plan to pay the difference. The Plan denied your request. The Plan 
says he denial of payment for this service is correct, because partial dentures are not covered by the Plan. Also, 
the Plan's call history verified no calls were made by the provider or the enrollee before the services were 
rendered. 
 
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 partial 
lower denture (D5214) provided on July 12, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice or home health care provided in patient's 
home/residence (Q5001) provided from July 19, 2021, to September 12, 2021. 
 
You asked the Plan to pay for the custodial care. You say that you provided services to the enrollee until 
December 26, 2021. You also say that non-coverage of these services would cause the enrollee's widow 
financial and emotional distress. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the custodial care have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Additionally, the record shows that the enrollee was enrolled in hospice on the 
dates of service in this case. Therefore, we decided that the Plan does not have to pay for the hospice or home 
health care provided in patient's home/residence (Q5001) provided from July 19, 2021, to September 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on July 15, 2022. 
 
You asked the Plan to pay for x-rays. You say that the services are a covered benefit. The Plan denied your 
request. The Plan says periapical x-rays (D0220, D0230) 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 pay for periapical 
x-rays (D0220, D0230) provided on July 15, 2022.