Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the thorax. 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that the enrollee is at high risk for 
malignancy. The Plan denied your request. The Plan says a CT scan of the thorax is not medically necessary. 
 
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 a CT scan of the thorax. Our reviewer 
says that the requested CT scan of the thorax is not medically necessary. Our physician reviewer found that the 
request for a chest CT is due to the need to follow a solitary pulmonary nodule, but there are no details about 
the nodule. Without this information, the medical necessity of a CT of the thorax has not been demonstrated. 
 
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 CT scan of the thorax have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the thorax.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on October 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided outside of the United States on July 
20, 2021. 
 
You asked the Plan to pay for dental services provided outside of the United States. You say that due to an 
illness in the family you couldnt get back to the United States. The Plan denied your request. The Plan says the 
plan does not cover care performed outside of the U.S. unless it is an emergency. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services provided outside of the United States on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on November 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel the services received on 
November 28, 2022, should be paid in full by your insurance. 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. This benefit includes a limit of 
$0 copay up to the $1,000 allowance for all covered dental services. You pay 100% of charges beyond the 
$1,000 allowance or if you exceed a service limit. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $85 on January 5, 2022, $126 on November 3, 2022, and $789 on November 28, 2022 
($85 + $126 + $789 = $1,000). Therefore, the annual maximum of $1,000 has been met. Therefore, we decided 
that the Plan does not have to pay more for dental services provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on September 27, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the services received on 
September 27, 2022, paid for by your insurance. 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. This benefit includes the 
requested item or service but is limited to $1,250 every year for non-Medicare covered preventive dental 
services and non-Medicare covered comprehensive dental services combined. You are responsible for any 
amount above the dental coverage limit. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $190 on March 8, 2022, $235 on March 23, 2022, $235 on May 10, 2022, $235 on May 
17, 2022, $98 on June 1, 2022, $213 on September 20, 2022, and $44 on September 27, 2022 ($190 + $235 + 
$235 + $235 + $98 + $213 + $44 = $1,250). Therefore, your annual benefit of $1,250 has been exhausted. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on September 27, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periapical x-ray, crown recementation and a dental 
exam provided on December 14, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider. 
 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for periapical x-ray, crown recementation and a 
dental exam provided on December 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transurethral waterjet ablation. You asked the Plan to pre-approve the requested services. You say that you are in pain. The Plan denied your 
request. The Plan says the indications for coverage have not been met. 
 
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 requested services. Our physician 
reviewer found that you have benign prostatic hyperplasia with lower urinary tract symptoms. Your IPSS is 10. 
You have a maximum flow rate is 18.1 mL/s. You have a prostate volume is 66.1 mL by ultrasound. The 
urocuff study is non-obstructive. The cystscopy shows BPH. The indications for coverage have not been met. 
The records do not show that the IPSS is greater than or equal to 12. Your maximum urinary flow rate is not 
less than or equal to 15 mL/s. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transurethral waterjet ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the custom sleep apnea appliance 
fabrication and placement (D9947) provided on May 24, 2022. 
 
You asked the Plan to issue reimbursement 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 this 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the custom sleep apnea appliance fabrication and placement (D9947) provided on May 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI. You say that you are requesting reconsideration for the denial of an 
MRI of the lumbar spine. The Plan denied your request. The Plan says the request does not meet Medicare or 
the Plan's coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has low back pain, a positive 
straight leg raise and bilateral hip pain. There is no neurologic deficit or red flag. There is no contraindication 
of a six week trial of physical therapy. The medical necessity of a lumbar MRI has not been established in the 
records provided. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306), 
myocardial strain imaging using speckle tracking (93356), and three dimensional (3D) rendering with 
interpretation and reporting (76376). 
 
You asked the Plan to pre-approve a TTE, myocardial strain imaging using speckle tracking, and 3D rendering 
with interpretation and reporting. You say that the enrollee has had a large unintentional weight loss and 
fatigue accompanied by night sweats. You also say that you were concerned the enrollee may have subacute 
bacterial endocarditis, and have ordered the echocardiogram to look at their heart valves. The Plan denied your 
request. The Plan says the information reviewed showed that the enrollee had an echocardiogram (2D) done in 
February of 2023, which did not show any abnormalities or other areas of concern that needed follow-up 
imaging. 
 
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 TTE, myocardial strain imaging using 
speckle tracking, and 3D rendering with interpretation and reporting. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a TTE was already performed in February 2023. Speckle-tracking imaging is an echocardiographic 
technique used in the assessment of myocardial function. Our reviewer found that there is insufficient support 
in the peer-reviewed literature demonstrating a significant benefit of such imaging of the heart in guiding 
optimal management of this enrollee. Our physician reviewer found that as such, myocardial strain imaging is 
considered experimental/investigational for the evaluation and management of this enrollee's medical 
condition. 
 
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 TTE, myocardial strain imaging using speckle tracking, and 3D rendering 
with interpretation and reporting have not been met. Therefore, we decided that the Plan does not have to pre-
approve a transthoracic echocardiography (TTE) (93306), myocardial strain imaging using speckle tracking 
(93356), and three dimensional (3D) rendering with interpretation and reporting (76376).
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 October 11, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
assessed by the ambulance crew and 30 minutes later you say that you had calmed down enough to head home. 
You also say that you should have a $50 copayment and the denial should be reconsidered for payment. 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 October 11, 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 October 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided October 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that these services were provided in good faith. The 
Plan denied your request. The Plan says these services could have been provided in-network. 
 
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 physician services provided October 31, 2022, by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve air ambulance services. 
 
You asked the Plan to pre-approve the requested services. You say that you have 4 hours to get to New York 
once you receive the call. The Plan denied your request. The Plan says the organ call is not an emergency 
situation. 
 
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 pre-approve the requested services. Our physician 
reviewer found that you have been accepted by the lung transplant program in New York. You are currently on 
the transplant list. The documentation does not support that you suffer from an illness or injury that 
contraindicates transportation by any means other than ambulance. The documentation does not support that 
your condition is such that the time needed to transport by ground, or the instability of transportation by 
ground, poses a threat to your survival or seriously endangers your health. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve air ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental evaluation (D0120) provided on November 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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. Therefore, we decided that the Plan does 
not have to pay for dental evaluation (D0120) provided on November 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the requested hospital bed. You say that the bed will help the enrollee be 
comfortable. The Plan denied your request. The Plan says the requested bed is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
We looked at the file and the rules. While a total electric hospital bed may be appropriate in this case, neither 
the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-
approve a total electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical ventilator. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide continuous 
positive airway pressure (CPAP) or bi-level CPAP therapy will be denied as not reasonable and 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 a home mechanical ventilator. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found provided records 
document that the home ventilator is being requested for use in Pressure Support with Safety Tidal Volume 
(PS/SVt) mode. As stated by the device manufacturer: "Pressure Support with Safety Tidal Volume (PS/SVt) 
mode is a Volume Assured Pressure Support (VAPS) mode often used to treat patients with chronic obstructive 
pulmonary disease (COPD) and neuromuscular disease (NMD)." This mode of ventilatory support could be 
provided by a BiPAP device with average volume assured pressure support (AVAPS) and a back-up rate. 
 
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 home mechanical ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home mechanical ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) 
and the comprehensive oral evaluation (D0150) rendered by the out-of-network (OON) provider on  
December 6, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) and the 
comprehensive oral evaluation (D0150) rendered by the out-of-network (OON) provider on December 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary, and your needs can be met in other settings. 
 
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 that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care.