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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says this item is not covered when used for the prevention of deep vein 
thrombosis during or after surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99397 provided on June 20, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the services. You say that you are requesting reconsideration of the denied 
charges. The Plan denied your request. The Plan says Medicare rules state that health plans can require 
enrollees to get care from network providers. 
 
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 procedure code 99397 provided on June 20, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CB Muscle Ezze PM EX2 provided on April 21, 2022. 
 
You asked the Plan to pay for the CB Muscle Ezze PM EX2. You say that you are requesting reimbursement 
for over-the-counter muscle relaxing pills. The Plan denied your request. The Plan says the service is not a 
covered benefit.  
 
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. Specifically, the 
supplement contains ingredients that are not approved supplements. Therefore, we decided that the Plan does 
not have to pay for the CB Muscle Ezze PM EX2 provided on April 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to provide a positron emission tomography (PET) scan. 
 
You asked the Plan to provide a positron emission tomography (PET) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the service is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Therefore, we decided that the Plan does not have to provide a positron 
emission tomography (PET) scan. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a positron emission tomography (PET) scan have not been met. Therefore, we decided that the 
Plan does not have to provide a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical procedure for isolation of tooth with rubber 
dam (D3910), the bone graft at time of implant placement (D6104x2) and the second stage implant surgery 
(D6011x2). 
 
You asked the Plan to pre-approve the surgical procedure for isolation of tooth with rubber dam (D3910), the 
bone graft at time of implant placement (D6104x2) and the second stage implant surgery (D6011x2).. You say 
that you are appealing this denial. The Plan denied your request. The Plan says the services are not covered 
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 pre-approve the surgical procedure for isolation of tooth with rubber dam (D3910), the bone graft at time of implant placement 
(D6104x2) and the second stage implant surgery (D6011x2).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips. 
 
You asked the Plan to pre-approve the additional non-emergency transportation trips. You say you need 
transportation for other appointments. The Plan denied your request. The Plan says you have already use up all 
of your trips in this benefit year. This request is denied because your Plan benefits for this service have been 
exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation trips.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT). 
 
You asked the Plan to pre-approve the PET scan. You say that the physician needs to evaluate whether the 
enrollee needs maintenance therapy with OPDIVO. The Plan denied your request. The Plan says the records do 
not show the enrollee has cancer; therefore, the PET scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the PET scan is not reasonable or medically necessary. Our physician reviewer found PET scans are not 
indicated for surveillance after treatment for esophageal cancer. This enrollee completed treatment in August of 
2021 and imaging recommendations are with a cat scan. 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed 
tomography (CT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has complex medical needs 
that require ongoing acute care. The Plan denied your request. The Plan says an LTACH should not take the 
place of treatment in an acute hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of 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 LTACH services. Our physician 
reviewer found that the enrollee was admitted to the acute care hospital with cardiac arrest, acute respiratory 
failure, multiple fractures, pneumothoraces, and lacerated spleen. The enrollee appears to be more stable and 
responding to current treatments and should only require short-term additional acute care hospital services that 
can safely be provided at the current facility. There are no services at the LTACH that the enrollee requires that 
are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary 
as the enrollee is not yet stable for transfer and as it would not be clinically advantageous. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on August 18, 2022, to 
August 30, 2022. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the subsequent nursing 
care provided on August 18, 2022, to August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on August 
29, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you shouldnt 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 $35 
copayment for Specialist office visits. 
 
You have been asked to pay a $35 copayment for specialist office visit. This item/service falls within the 
Specialist 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 specialist 
office visit provided on August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external infusion pump. 
 
You asked the Plan to pre-approve an external infusion pump. You say that the item is medically necessay. The 
Plan denied your request. The Plan says the member does not meet the criteria for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that an external chemotherapy infusion pump is 
covered when used in the treatment of primary hepatocellular carcinoma or colorectal cancer where this disease 
is unresectable; OR, where the patient refuses surgical excision of the tumor. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an external infusion pump have not been met. Specifically, the records do not show that the 
external chemotherapy infusion pump is requested for the use of treating primary hepatocellular carcinoma or 
colorectal cancer where this disease is unresectable; OR, where the patient refuses surgical excision of the 
tumor. Therefore, we decided that the Plan does not have to pre-approve an external infusion pump.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need these items. The Plan denied 
your request. The Plan says these items 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 pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, of an erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140 x 4) and the maxillary partial dentureresin base (including, 
retentive/clasping materials, rests, and teeth) (D5211) provided on August 17, 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 are not payable as the claim was 
submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until September 23, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the extractions, of an erupted tooth or exposed root (elevation and/or forceps 
removal) (D7140 x 4) and the maxillary partial dentureresin base (including, retentive/clasping materials, 
rests, and teeth) (D5211) provided on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the neck spine 
(72141). 
 
You asked the Plan to pre-approve an MRI of the neck spine. You say that you need an MRI because you are in 
a lot of pain. The Plan denied your request. The Plan says the current evidence does not meet medical necessity 
criteria for the requested imaging. The Plan also says that according to the provider, you have been referred to 
an orthopedist for appropriate evaluation. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the neck spine. Our 
physician reviewer found the record indicates that the enrollee has lower abdominal pain after mesh surgery. 
The record does not indicate the presence of red flag symptoms or neurologic abnormalities attributable to the 
thoracic spine. Our reviewer found that the requested service is not medically necessary and reasonable for the 
diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria 
are not satisfied. Our physician reviewer also found that the requested service cannot be recommended. 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the neck spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the neck spine (72141).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on December 03, 
2021. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you shouldnt 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 $50 
copayment for Urgently needed services. 
 
You have been asked to pay a $50 copayment for urgent care visit. This item/service falls within the Urgently 
needed 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 urgent care visit provided 
on December 03, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 
4, 2022, to July 7, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you cannot afford the 
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 $250 
per day for days 1-3 for inpatient hospital care.  
 
The file shows that you were in the hospital for 3 days from July 4, 2022, to July 7, 2022. There is no 
copayment for the discharge date. You have been asked to pay $250 per day for only 2 days for the inpatient 
hospital care. The total for your stay is $500. This item/service falls within the inpatient hospital care 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 inpatient hospital care provided from July 4, 
2022, to July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of an erupted tooth or exposed root (D7140) 
provided on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the extraction of your tooth was necessary due 
to an infection. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental 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. 
 
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 the 
extraction of an erupted tooth or exposed root (D7140) provided on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive periodontal evaluation (D0180), 
bitewing x-rays-four radiographic images (D0274), intraoral-periapical first radiographic image (D0220), and 
the scaling in the presence of generalized moderate or severe gingival inflammationfull mouth, after an oral 
evaluation (D4346) provided on September 7, 2022. 
 
You asked the Plan to pay more for these dental services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Additionally, scaling in the presence of generalized moderate or severe gingival inflammation after 
an oral evaluation 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, scaling in the presence of generalized moderate or severe gingival inflammation after an oral 
evaluation is not a covered benefit. Therefore, we decided that the Plan does not have to pay more for the 
comprehensive periodontal evaluation (D0180), bitewing x-rays-four radiographic images (D0274), intraoral-
periapical first radiographic image (D0220), and the scaling in the presence of generalized moderate or severe 
gingival inflammationfull mouth, after an oral evaluation (D4346) provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211) and mandibular 
partial denture (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain and cannot eat properly. 
The Plan denied your request. The Plan says these services are not covered by the Plan's 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 pre-approve a 
maxillary partial denture (D5211) and mandibular partial denture (D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Durable medical equipment provided on 
July 06, 2022. 
 
You asked the Plan to waive the coinsurance for Durable medical equipment. You say that this should 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 Durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for Durable medical equipment. This item/service falls within 
the Durable medical equipment (DME) 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 Durable medical equipment provided on July 06, 2022.