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

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and the 
extraction of an erupted tooth (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that you have chronic obstructive pulmonary 
disease (COPD). You also say your tooth is infected and decayed, causing a lot of pain. The Plan denied your 
request. The Plan says dental services from an out-of-network provider 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 Plan's coverage rules apply in this case. 
 
You are requesting 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 pre-approve a 
comprehensive oral evaluation (D0150), and the extraction of an erupted tooth (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided from 
October 13, 2021, through November 10, 2021. 
 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 at issue are not payable as they 
were rendered by a non-covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
provided under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 
97811) provided from October 13, 2021, through November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee's medical condition would 
benefit from a home ventilator. The Plan denied your request. The Plan says your records have been reviewed 
and they show chronic obstructive pulmonary disease (COPD) with home oxygen supplementation. The 
enrollee had an overnight capnography on October 18, 2022, which did not demonstrate any desaturation below 
89% and he did not have a recommendation for overnight oxygen therapy. Records do not demonstrate an 
arterial oxygen or carbon dioxide level. The doctor is requesting to use noninvasive ventilation in a program 
that can be used in bilevel positive airway pressure (BiPap), called volume-assured pressure support. The 
request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD. Overnight 
capnography suggests nocturnal hypoventilation, but chronic CO2 retention is not confirmed with an ABG 
done while awake and stable, as required by Medicare. If the enrollee does have chronic CO2 retention, he may 
benefit from BiPAP with AVAPS during sleep.  Medicare does not cover a home ventilator when used as 
BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on July 1, 2022, 
to July 26, 2022. 
 
You asked the Plan to waive the copayment for physical therapy. You say that this was the surgeon's fault. You 
say that you should not have to pay for this. 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 $20 
copayment for outpatient rehabilitation services.  
 You have been asked to pay a $20 copayment for each physical therapy. The total amount you are being asked 
to pay is $100 ($20 x 5 visits = $100). This item/service falls within the outpatient rehabilitation services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for physical therapy provided on 
July 1, 2022, to July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 3, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 an office visit provided on August 3, 2022, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), repair false teeth 
(D5650), and removal of tooth or tooth root (D7140) provided June 25, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the dental services. You say that you would like these services 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 the comprehensive oral exam (D0150), repair false teeth (D5650), and removal of tooth or tooth root 
(D7140) provided June 25, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair purchased online on July 25, 2022. 
 
You asked the Plan to pay for the wheelchair. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was purchased through a provider, who is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the wheelchair purchased online on July 
25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on June 21, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you are disputing the share cost. 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 $35 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $35 copayment for office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for office visit provided on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and drugs, or 
medicaments dispensed in the office for home use provided on August 23, 2022. 
 You asked the Plan to pay for the dental services. You say that you were unaware the provider is out-of-
network, and you believed the mouthwash was a free sample. The Plan denied your request. The Plan says your 
claim was correctly processed at the out-of-network rate and one 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 item or service is not 
among those covered under this benefit. Additionally, the cost share for the out-of-network oral evaluation was 
processed correctly. Therefore, we decided that the Plan does not have to pay for the problem focused limited 
oral evaluation and drugs, or medicaments dispensed in the office for home use provided on August 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on February 
16, 2022, 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you feel the copayment is to 
high. 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 $370 
copayment for in-network outpatient surgery/Medicare-covered surgery provided at outpatient hospital.  
 
You have been asked to pay a $370 copayment for an outpatient surgery. However, you are only being charged 
$368.48. This item/service falls within the in-network outpatient surgery/Medicare-covered surgery provided at 
outpatient hospital 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 outpatient surgery 
provided on February 16, 2022,
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 7, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you feel you should not have to 
pay for the second mammogram or ultrasound. 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 $100 
copayment per day for a Medicare-covered ultrasound.  
 
You have been asked to pay $92.06 which is less than the standard $100 copayment. The ultrasound falls 
within the outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound provided on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
August 16, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you had to find a new dentist 
because you moved, and feel this service should be approved for payment. The Plan denied your request. The 
Plan says your benefit for the requested 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 service was exhausted on date of service June 10, 2020. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 
16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on August 16, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinic visit. You say that you do not understand why this 
service is not covered. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advanced. 
 
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 hospital outpatient clinic visit provided on August 
16, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for you to receive IRF care. 
The Plan denied your request. The Plan says that the Medicare guidelines for IRF admission were not met and 
the enrollee can receive the services that they need at a 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the clinical documentation shows that the enrollee has complex functional deficits (dysphagia on 
tube feeds, cognitive impairments in addition to mobility and self-care impairments). Evaluating therapists 
(physical therapy, occupational therapy, and speech and language pathologist) recommend intense therapy in 
an IRF setting. Clinical documentation shows that the enrollee has active medical comorbidities, and the 
enrollee has neuro-Behavioral impairments. Thus, the enrollee would be expected to require close medical 
supervision during rehabilitation. The complexity of the enrollee's nursing, medical and rehabilitation needs 
documented require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 been met. Therefore, we decided that the Plan has to pre-approve 
IRF admission and services.  
  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoe inserts (A5500x2, A5513x6) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve diabetic shoe inserts. You say that you have received your diabetic shoes 
and inserts from this provider for the last 10 years. You have never had an issue obtaining these items until you 
switched to a different plan. You are requesting approval to continue with this provider. The Plan denied your 
request. The Plan says the requested vendor is not contracted with your Plan. The requested items are available 
in-network. You must use network providers to get your medical care and services. 
 
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 
diabetic shoe inserts (A5500x2, A5513x6) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that the denial of payment is incorrect. The Plan denied 
your request. The Plan says the rules for payment have not been made. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the lab services at issue were not billed with a valid modifier as required. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 19, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the provided medical documentation shows 
proof the services were rendered. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
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 laboratory services provided on August 19, 2022, 
by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on July 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 nursing facility care provided on July 8, 2022, by 
an out-of-network (OON) provider.