Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair items. 
 
You asked the Plan to pre-approve the wheelchair items. You say that the wheelchair items are necessary. The 
Plan denied your request. The Plan says the wheelchair items are not necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. The seat lift and 
backpack holder do not serve a primary medical purpose. The upgraded electronics (expandable controller, 
harness and electronic connector to 2 power options) are not medically necessary. They are necessary when 
there is a medical need to control power options though the joystick. The notes do not show a medical need to 
control the power options through the joystick. The power options can be controlled using their own switches. 
These switches can be made any size without asking for a separate request. They can be made from any 
material without asking for a separate request. All of this can be done without the need to use the joystick to 
control the power features. The positioning wedges are already included with the approved cushions and cannot 
be requested separately. The delivery fees are already included with the wheelchair can cannot be requested 
separately. An attendant control cannot be approved for a wheelchair with a user-operated control. Therefore, 
we decided that the Plan does not have to pre-approve the wheelchair items.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) provided on March 15, 2022. 
 
You asked the Plan to pay for the dental item. You say that you had a medical situation that was out of your 
control. You also say that you need a replacement denture. The Plan denied your request. The Plan says your 
benefit for the complete upper denture 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 Plan's 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 complete upper denture was exhausted on date of service April 14, 2021. Therefore, 
we decided that the Plan does not have to pay for the complete upper denture (D5110) provided on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to a new dentist. 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 September 28, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D7140, D0330, D0140, D0230) 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says one of the services do not fall within your dental 
benefits and your benefit for the other requested items or services have 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 Plan's 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 07/28/2021. Therefore, 
we decided that the Plan does not have to pay for the dental services (D7140, D0330, D0140, D0230)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0383) provided on January 12, 2022. 
 
You asked the Plan to pay for imaging. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says cone beam imaging (D0383) is not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone 
beam imaging (D0383) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided by a non-
network provider on March 9, 2022. 
 You asked the Plan to pay for the complete maxillary denture (D5110). You say that you should have been told 
by the Plan to locate an in-network dentist to get services rendered. The Plan denied your request. The Plan 
says the dentures are covered at 50% when you go out-of-network. 
 
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 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 50% for 
complete upper dentures when you go out-of-network. 
 
You have been asked to pay $1,049.50 the complete maxillary denture falls within the Dental services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
 
Date of 
Service 
Service Amount 
Billed 
(AB) 
Allowed 
Amount 
(AA) 
Coinsurance Difference 
between 
AB and 
AA 
Coinsurance 
Amount 
Total 
March 9, 
2022 
D5110) $1,450 $801.00 50% $649 $400.50 $1,049.50 
Total       $1,049.50 
 
Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided 
by a non-network provider on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the tooth extraction (D9999) provided on 
March 10, 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 the tooth extraction is not 
payable as it was not performed by a participating general dentist. 
 
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. 
 
We reviewed the case file and the Plans rules. Based on this information, we decided that you do not meet 
criteria for coverage of this service provided. Specifically, the tooth extraction in this case was performed by an 
out-of-network oral surgeon. The Plan contract states that dental services must be performed by a participating 
general dentist. Therefore, we decided that the Plan does not have to issue reimbursement for the tooth 
extraction (D9999) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay an additional $60.16 for the vision supply, accessory, or service component 
(V2797) and frames/lens package provided on March 30, 2022. 
 
You asked the Plan to pay more for the vision supply, accessory, or service component and frames/lens 
package. You say that you needed the exam and glasses. The Plan denied your request. The Plan says that the 
vision supply, accessory, or service component is not a covered benefit. 
 
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. 
 
We looked at the file and the Plan's rules. The contract says you have a $300 benefit to use toward the purchase 
and fitting of eyeglasses and pair of lenses per calendar year. You are responsible for any amount over the $300 
retail price. The record shows that the allowed amounts for these services totaled $240.16, and the Plan paid 
$180 toward the frames/lens package, leaving you with a responsibility of $60.16. The contract does not clearly 
state that the vision supply, accessory, or service component is not a covered benefit. You reasonably believed 
this service would be covered because it was part of the package you received. The record also does not show 
that your $300 benefit was exhausted on this date of service. Based on this information, we decided that the 
Plan's rules for coverage of the vision supply, accessory, or service component and frames/lens package have 
been met. Therefore, we decided that the Plan has to pay an additional $60.16 for the vision supply, accessory, 
or service component (V2797) and frames/lens package provided on March 30, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0364) provided on June 7, 2021. 
 
You asked the Plan to pay for imaging. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says cone beam imaging (D0364) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone 
beam imaging (D0364) provided on June 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on March 17, 2022. 
 
You asked the Plan to reduce the copayment for the CT scan. You say that the hospital was the only facility 
where the test could be performed. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $275 
copayment for advanced imaging services at an outpatient hospital.  
 
 
 
 
 
 
 You have been asked to pay a $275 copayment for the CT scan. The CT scan 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 reduce 
the copayment for a computed tomography (CT) scan of the abdomen and pelvis provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency telehealth visit provided on 
May 6, 2022. 
 
You asked the Plan to waive the copayment for the emergency telehealth visit. You say that you should not be 
responsible for the copayment for a 2 minute phone call that was made to you. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
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 $15 
copayment for specialist telehealth services.  
 
You have been asked to pay a $15 copayment for the emergency telehealth visit. The emergency telehealth 
visit 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 an emergency telehealth visit provided on May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical or thoracic facet injections (CPT code(s): 
64490 and 64491). 
 
You asked the Plan to pre-approve the injections. You say that the enrollee has cervical spondylosis with right 
neck pain that radiates to the posterior occipital area and upper right shoulder. You state that the enrollee is 
recommended right C3, C4, and C5 medial branch blocks. The Plan denied your request. The Plan says there is 
no documentation as to why radiofrequency ablation is not medically appropriate for the enrollee. 
 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 injections. Our physician reviewer 
found the repeat radiofrequency ablation (RFA) is indicated but there is insufficient data to support cervical 
interventions. Cervical medial branch blocks (MBB) are not medically reasonable or 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical or thoracic facet injections (CPT code(s): 64490 and 64491).
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 you cannot take care of yourself and are living alone. 
You say that you are at risk of injury and need to be admitted to an IRF to receive the help you need. The Plan 
denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the 
enrollee could receive care in another setting. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for cellulitis and congestive heart failure and was discharged on August 13, 2022. There is 
ongoing weakness. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 resin-based composite-one surface, posterior (D2391) 
provided on January 22, 2022. 
 
You asked the Plan to pay 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 under 
your contractual policy. 
 
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 pay for the resin-based 
composite-one surface, posterior (D2391) provided on January 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lead wires (CPT code A4557) and electrical stimulator 
supplies (CPT code A4595) provided on March 16, 2022. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation submitted did not sufficiently support the billed supply code. 
 
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 the DME. Our physician reviewer found 
there is insufficient documentation to support the use of this device. It was not medically reasonable or 
necessary based on the documentation submitted. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pay for lead wires (CPT code A4557) and electrical stimulator supplies (CPT code A4595) provided on 
March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guidance for radiation therapy. 
 
You asked the Plan to pre-approve ultrasound guidance. You say that this is required prior to treatment 
delivery. The Plan denied your request. The Plan says ultrasound guidance is not medically necessary. 
 
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 ultrasound guidance. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found billing for daily image-guided radiation therapy (IGRT) for a technology for which 
need has not been established by published data or supported by consensus guidance would not be furnished in 
accordance with accepted standards of medical practice. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guidance have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ultrasound guidance for radiation therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 16, 2021 billed 
with codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 16, 2021 billed with codes 81206 and 81292.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
December 2, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford 
the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $305 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $305 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
ambulance transportation provided on December 2, 2021.