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

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
August 25, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan contract says that enrollees must purchase 
hearing aids through the Plans select hearing aid provider. Hearing aids ordered through providers other than 
the Plans select hearing aid vendor are not covered. The hearing aids in this case were purchased from an  
out-of-network provider. Therefore, we decided that the Plan does not have to issue reimbursement for the 
hearing aids (V5261) purchased on August 25, 2022.
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 services are necessary for the enrollee to receive 
the therapies needed before returning home. The Plan denied your request. The Plan says the enrollee can 
safely receive the services needed in another setting such as a skilled nursing facility, home with home health 
services or home with outpatient therapy. 
 
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 have any documented extensive therapy needs.  While the 
enrollee might benefit from physical or occupational therapy, their rehab needs can be met in a lower level of 
care such as a skilled nursing facility or in the home with 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: 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 services are necessary while you heal so you can 
return home independently. The Plan denied your request. The Plan says the services you need can be provided 
safely in other settings such as a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 
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 you are medically stable, and the records received do not show the need for extensive 
therapies. While you may benefit from physical or occupational therapy, your rehab therapies can be provided 
in a lower level of care such as a skilled nursing facility. 
 
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 (D0220 and D2950) on October 5, 2022. 
 
You asked the Plan to pay for the dental services (D0220 and D2950). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the requested 
dental service (D0220) has already been exhausted. The dental service (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, certain limitations apply. The record 
shows your benefit for the requested dental service (D0220) was exhausted on date of service September 28, 
2022. There is no coverage for the dental service (D2950). Therefore, we decided that the Plan does not have to 
pay for the dental services (D0220 and D2950) on October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
January 4, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items at issue are not payable 
as they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan contract states that hearing aids must be  
purchased from the Plans select hearing aid provider. Hearing aids ordered through providers other than the 
Plans hearing aid vendor are not covered. The hearing aids in this case were purchased from an out-of-network 
provider. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids 
(V5261) purchased on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0220, D0140, and D0270) on August 
11, 2022. 
 
You asked the Plan to pay for the dental services (D0220, D0140, and D0270). You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the 
requested dental services (D0140, and D0270) has already been exhausted. The dental service (D0220) is a 
covered benefit; however, the enrollee has already met the annual benefit maximum of $1,500. 
 
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 3, 2022, and 
March 5, 2022. Therefore, we decided that the Plan does not have to pay for the dental services (D0220, 
D0140, and D0270) on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary and mandibular denture (D5110 and 
D5120) provided on October 12, 2022. 
 
You asked the Plan to pay for a complete maxillary and mandibular denture. You say that you believe the Plan 
should pay for this. The Plan denied your request. The Plan says the rendered dental services 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 a 
complete maxillary and mandibular denture (D5110 and D5120) provided on October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 12, 2016. 
 
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 January 12, 2016.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy (D3330) for tooth #19 provided 
on September 21, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you are requesting the Plan to pay more for 
the dental service. The Plan denied your request. The Plan says your yearly dental benefit 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 yearly dental benefit was exhausted on the date of service of September 21, 2022. On February 1, 
2022, the Plan paid $145 for dental services. On August 3, 2022, the Plan paid $145 for dental services. On 
September 21, 2022, the Plan paid $710 for dental services. For the year of 2022 the Plan paid $1,000 ($145 
paid + $145 paid + $710 paid) for dental services. Therefore, we decided that the Plan does not have to pay 
more for the endodontic therapy (D3330) for tooth #19 provided on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home delivered meals (S5170). 
 
You asked the Plan to pre-approve additional home delivered meals (S5170). You say that you had food 
delivery for 4 weeks but no longer have it, and you are being charged for an additional 4 weeks. You also say 
that you do not feel that you should be charged for the additional four weeks. The Plan denied your request. 
The Plan says you do not meet the coverage criteria established. 
 
The Plan must follow Medicare rules. Medicare rules say that cover meals delivered to the enrollee's home 
immediately following discharge from a network hospital or skilled nursing facility as an inpatient, up to three 
meals per day in a consecutive four-week period, once per calendar year.  
 
 
  We looked at the file and Medicare rules. The rules say the Plan will cover home delivered meals after a 
discharge for a consecutive four-week period, once per calendar year. The records shows that this benefit has 
been exhausted. Based on this information, we decided that Medicare rules for coverage of additional home 
delivered meals (S5170) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional home delivered meals (S5170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aflibercept injection provided on 
August 24, 2022. 
 
You asked the Plan to waive the coinsurance for an aflibercept injection. You say that the sales representative 
from the Plan reassured you that the eye injections would 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 20% 
coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs.  
 
 
  You have been asked to pay $356.16, which is 20% coinsurance of the allowed amount for an aflibercept 
injection ($1,825.78 allowed amount x 20% coinsurance = $365.16). This item/service falls within the 
Medicare-covered Part B chemotherapy drugs and other Part B drugs 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 coinsurance for an aflibercept injection provided on August 24, 2022.
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 services are necessary for the enrollee to receive 
the care needed and return home independently. The Plan denied your request. The Plan says the enrollee can 
receive the needed services in an alternate setting such as in a skilled nursing facility, outpatient setting or 
home health care. 
 
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 there are no documented extensive therapy needs. While the enrollee might benefit 
from physical or occupational therapy, the enrollee's rehab needs can be met in a lower level of care such as in 
a skilled nursing facility. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on September 
12, 2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the test was necessary due to an 
inconclusive mammogram. 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 for diagnostic radiology services (ultrasound).  
 
You have been asked to pay $96.70, which is less than the $100 copayment for the ultrasound. This 
item/service falls within the diagnostic radiology services (ultrasound) 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 a breast ultrasound provided on September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 24, 2022. 
 
You asked the Plan to pay for lab services. You say that tests were ordered by their doctor to help select the 
appropriate treatment to achieve the best possible outcome. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on June 8, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for lab services provided on 
June 24, 2022.
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 services are necessary for the enrollee to improve 
mobility before returning home. The Plan denied your request. The Plan says the enrollee could receive care in 
another setting such as a skilled nursing facility, outpatient setting or home health care. 
 
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 has no documented extensive therapy needs.  While the enrollee may 
benefit from physical or occupational therapy, their rehab needs can be met in a lower level of care such as a 
skilled nursing facility or with home 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 extraction, coronal remnants  primary tooth (D7111), and 
extraction, erupted tooth requiring removal of bone tooth #5 (D7210) provided on August 31, 2022, and 
September 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had a broken tooth and the dentist said you 
needed 4 teeth pulled. You also say that you were told you had $2,000 for coverage on everything but you 
received a bill for $1,672. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted or is not covered under the Plans dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the extraction, erupted tooth requiring removal of bone (D7210) was exhausted on date 
of service August 31, 2022.  Therefore, we decided that the Plan does not have to pay for extraction, coronal remnants  primary tooth 
(D7111), and extraction, erupted tooth requiring removal of bone tooth #5 (D7210) provided on August 31, 
2022, and September 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on 
March 27, 2022. 
 
You asked the Plan to pay for the CT scan. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
  We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 6, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the CT scan have not been met. Therefore, 
we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on 
March 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral 
radiographic images (D0210), a cleaning (D1110), and a resin-based composite (D2393) for tooth #31 provided 
on November 2, 2022, and November 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider did not tell you that they were out-
of-network until after you got the dental services done. 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 a comprehensive oral evaluation (D0150), intraoral radiographic images (D0210), a cleaning 
(D1110), and a resin-based composite (D2393) for tooth #31 provided on November 2, 2022, and November 9, 
2022.