Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 26, 2022, 
to March 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted. 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 February 26, 2022, to 
March 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth, or exposed root (D7140) provided 
on December 22, 2022. 
 
You asked the Plan to pay for an extraction. You say that this should be covered. The Plan denied your request. 
The Plan says these are not covered services. 
 
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 
extraction, erupted tooth, or exposed root (D7140) provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve 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 on date of service January 14, 2021. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and 
complete denture - mandibular (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330), extraction, erupted 
tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if 
indicated (D7210) and inhalation of nitrous oxide/analgesia, anxiolysis (D9230) provided on November 10, 
2022. 
 
You asked the Plan to pay for dental services. You say that you disagree with the denial of services because 
they were needed as part of your plan of care. The Plan denied your request. The Plan says these services are 
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. Panoramic radiographic image 
(D0330), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation 
of mucoperiosteal flap if indicated (D7210) and inhalation of nitrous oxide/analgesia, anxiolysis (D9230) are 
not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0330, D7210 and 
D9230 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for panoramic radiographic image (D0330), extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and inhalation of 
nitrous oxide/analgesia, anxiolysis (D9230) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) provided on December 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware there was a frequency limit 
for this service. 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 December 14, 2022. This 
claim processed before the December 2, 2022 date of service. Therefore, we decided that the Plan does not 
have to pay for an intraoral - complete series of radiographic images (D0210) provided on December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a basic pneumatic compressor (E0651). 
 
You asked the Plan to pre-approve a basic pneumatic compressor. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 basic pneumatic compressor. Our 
reviewer says that you do not need this medical item. Our physician reviewer found the medical records are 
unclear with regard to the required four-week trial of conservative treatment. 
 
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 basic pneumatic compressor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a basic pneumatic compressor (E0651).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from October 11, 2022, to November 9, 
2022. 
 You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says the enrollee no longer had 
skilled nursing facility needs 
 
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 pay for 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 the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did 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 pay for SNF care provided from October 11, 2022, to November 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incontinence supplies provided on December 17, 2022. 
 
You asked the Plan to pay for the incontinence supplies. You say that the enrollee needed these supplies. The 
Plan denied your request. The Plan says the supplies in this case are not covered by Medicare or the Plan. 
 The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for the incontinence supplies provided on 
December 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a PET scan provided on January 4, 2023. 
 
You asked the Plan to waive the cost share for a PET scan. You say that you were not aware you would owe 
anything more than the $85 copayment. 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 an $85 
copayment for a PET scan and 20% coinsurance for Part B drugs and contrast materials used in conjunction 
with outpatient diagnostic services.  
 
  You have been asked to pay a total cost share of $1,038.06 for a PET scan. This total includes an $85 
copayment for a PET scan and $953.06 coinsurance for Part B drug ($4,765.29 allowed x 20% = $953.06). 
These items/services fall within the Outpatient Diagnostic Tests 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 cost share for a PET scan provided on January 4, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service December 
16, 2022. 
 You asked the Plan to pay for procedure code 76700. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into 
payment for code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76700 billed for date of service December 16, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services and the chest x-ray 
provided on January 13, 2023. 
 You asked the Plan to pay for the ER services and the chest x-ray. You say that the enrollee was not enrolled in 
hospice on the date of service. The Plan denied your request. The Plan says the services should be billed under 
Original Medicare. 
 
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 the emergency room (ER) services and the chest x-ray 
provided on January 13, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve speech therapy services. 
 
You asked the Plan to pre-approve speech therapy services. You say that the laryngeal function studies will 
improve the members awareness skills and strengthen overall outcome. The Plan denied your request. The 
Plan says there is no reasonable expectation of meaningful and lasting gains with additional skilled therapy. 
 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 speech therapy services. 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 speech therapy does not improve brain function for 
enrollees with dementia. The therapy requested is not necessary for the enrollee's 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 speech therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve speech therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the primary care provider (PCP) office visit 
provided on November 3, 2022. 
 You asked the Plan to waive the cost share for the PCP office visit. You say that this was an annual wellness 
visit. 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. Your 
contract with the Plan says that there is an $800 deductible which applies to in-network primary care provider 
office visits. Your contract with the Plan also says that you must pay 10% coinsurance after meeting the 
deductible for in-network primary care provider office visits. 
 
You have been asked to pay $89.42 towards your deductible. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is an $800 deductible which applies to in-network primary care provider 
office visits. This cost sharing is a contractual obligation that had not been met at the time the primary care 
provider office visit was received on November 3, 2022. 
 
You have also been asked to pay $12.44, which is 10% coinsurance for the PCP office visit. This item/service 
falls within the doctor and other health care provider services benefit category. You have been asked to pay a 
total of $101.86 ($89.42 deductible + $12.44 coinsurance = $101.86). 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 
cost share for the PCP office visit provided on November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the records attached support these services. The 
Plan denied your request. The Plan says these services can be provided from an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a CT scan provided on December 16, 2022. 
 
You asked the Plan to reduce the cost share for a CT scan. You say that your provider stated this service was 
necessary and you feel the Plan should cover more of the claim. 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 20% 
coinsurance for Medicare-covered Part B drugs and a $300 copayment for diagnostic imaging, including CT 
scans.   You have been asked to pay a total cost share of $285.48 for a CT scan. This total includes $283.56 for a CT 
scan, which is less than the standard $300 copayment, and $1.92 coinsurance for an injection ($9.60 allowed x 
20% = $1.92). The injection falls within the Medicare Part B Prescription Drug benefit category. The CT scan 
falls within the Outpatient Diagnostic Tests 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 cost share 
for a CT scan provided on December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 24, 2022, to October 28, 
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 August 24, 2022, to October 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo carotid sinus baroreflex device. 
 
You asked the Plan to pre-approve a Barostim Neo carotid sinus baroreflex device. You say that this service is 
medically necessary. The Plan denied your request. The Plan says this is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Barostim Neo carotid sinus baroreflex 
device. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found this is considered experimental. 
 
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 Barostim Neo carotid sinus baroreflex device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Barostim Neo carotid sinus baroreflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you do not understand why you cannot get 
this benefit if you are on bed rest and cannot get out of bed. The Plan denied your request. The Plan says the 
criteria for eligibility have not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
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 have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses provided on August 8, 2022. 
 You asked the Plan to pay for the contact lenses. You say that you have kerataconus, a corneal transplant, 
glaucoma, a severe injury, and a lens implant. The Plan denied your request. The Plan says this service is not 
covered by the plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The service you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the contact lenses provided on August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens, the anti-reflective coating, and the 
addition to lens provided on November 21, 2022. 
 
You asked the Plan to pay for the vision services. You say that the enrollee did not receive the handbook and 
was not aware of her benefits. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
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 received in-network. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, 
we decided that the Plan does not have to pay for the progressive lens, the anti-reflective coating, and the 
addition to lens provided on November 21, 2022.  
 
Your complaint about the Plan taking advantage of elderly enrollees is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.