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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested ventilator. You say that BiPAP settings resulted in 
hypoxemia. The Plan denied your request. The Plan says the device does not meet the enrollee's medical needs. 
 
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 the requested ventilator. Our physician 
reviewer found that the enrollee as severe COPD, severe obesity, likely obesity-hypoventilation syndrome, 
pulmonary hypertension, and obstructive sleep apnea. The baseline arterial blood gas showed mild chronic 
carbon dioxide retention. A PAP titration study showed significant baseline hypoxemia, which persisted with 
BiPAP. The enrollee did best on intelligent volume-assured pressure support (IVAPS).  IVAPS can be provided with BiPAP. This has not been tried as an outpatient. Also, the enrollee is not using the 
ventilator enough to be effective, or to meet minimum Medicare requirements of at least 4 hours per night for 
70% of nights. Therefore, a home ventilator is not medically 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 requested ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cleaning (D1110), the bitewing x-rays (D0274), the 
periodic oral evaluation (D0120), and each additional periapical x-rays (D0230) provided by an out-of-network 
provider on April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not told that the new dentist did not 
accept your insurance. 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 cleaning (D1110), the bitewing x-rays (D0274), the periodic oral evaluation (D0120), and each 
additional periapical x-rays (D0230) provided by an out-of-network provider on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on July 15, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
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 lab testing provided on July 15, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), x-ray exam of the cervical spine 
(72040), and the x-ray exam of the lumbar spine (72100) provided on March 16, 2022. 
 
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 these services are not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203), x-ray exam of the cervical spine (72040), and the 
x-ray exam of the lumbar spine (72100) provided on March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a metal-ceramic retainer (D6076) provided on April 13, 2022 
by an out-of-network provider. 
 
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 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 metal-ceramic retainer (D6076) provided on April 13, 2022 by an out-of-network provider.
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 you would like the home ventilator because 
without it, you can go into respiratory failure. The Plan denied your request. The Plan says you do not meet the 
requirements for approval for the home ventilator you are requesting. 
 
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 a home ventilator is not medically necessary. Our physician reviewer found this enrollee has a diagnosis of 
COPD, although there are no pulmonary function test results. There are also diagnoses of heart failure with 
preserved ejection fraction, obstructive sleep apnea, and obesity-hypoventilation syndrome. Our reviewer 
found that arterial blood gases (ABGs) in the hospital were consistent with acute on chronic hypercarbic 
respiratory failure, but there is no ABG done while stable to confirm chronic carbon dioxide (CO2) retention. If 
the enrollee does have chronic CO2 retention, they may benefit from bilevel positive airway pressure (BiPAP) 
with intelligent volume-assured pressure support. Our physician reviewer also found that 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
imaging (D0220 and D0230) provided by a participating provider on June 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware of what x-rays were covered 
and which ones were not. The Plan denied your request. The Plan says your benefit for D0150 has already been 
exhausted. The Plan says that D0220 and D0230 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, certain limitations apply. The record 
shows your benefit for D0150 was exhausted on date of service February 15, 2021. This benefit does not 
include D0220 or D0230. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150) and intraoral imaging (D0220 and D0230) provided by a participating provider on June 10, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a computed tomography (CT) scan 
provided on July 22, 2022. 
 
You asked the Plan to waive the coinsurance for a CT scan. You say that you should not have a payment for a 
CT scan. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance up to $75 per day for outpatient diagnostic tests and therapeutic services and 
supplies. The allowed amount of this drug or item is $149.14, resulting in a coinsurance amount of $29.83 
($149.14 x 20% = $29.83). 
 
The enrollee has been asked to pay a $29.83 for a CT scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan.  This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to waive the coinsurance for a computed tomography (CT) scan 
provided on July 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lumbar injections on March 2, 2022. 
 
You asked the Plan to waive the copayment for lumbar injections. You say that you would like to appeal the 
cost share. 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 $250 
copayment for lumbar injections.  
 
You have been asked to pay a $250 copayment for lumbar injections. This item/service 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 lumbar injections on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a participating provider on 
August 10, 2022. 
 
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 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 annual maximum dental allowance was exhausted on date of service August 10, 2022. Therefore, 
we decided that the Plan does not have to pay for the remaining balance for dental services provided by a 
participating provider August 10, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services provided on December 20, 
2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that a valid 
interim rate needs to be submitted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Plan denied services requiring an interim rate. However, the 
documentation provided does not indicate that the provider is a newly certified rural health clinic. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Therefore, we decided that the Plan has to pay for the evaluation and management services 
provided on December 20, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on August 31, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing have been met. No 
clinical records were submitted to support the services billed. Only lab results were provided. Therefore, we 
decided that the Plan does not have to pay for genetic testing (81479) provided on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis 
 
You asked the Plan to pre-approve 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 the services denied correctly as they do 
not fall within 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
removal of torus mandibularis
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on July 12, 2022. 
 
You asked the Plan to pay for the dental services. 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 August 7, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150) provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1208) provided 
on July 5, 2022. 
 
You asked the Plan to pay for the topical application of fluoride varnish. You say that this service should be 
covered because it is preventive, medically necessary, and your dentist advised it was beneficial to prevent 
decay. The Plan denied your request. The Plan says this service is 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 the 
topical application of fluoride varnish (D1208) provided on July 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment provided from June 9, 
2022, to July 9, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment. You say that you need a smaller oxygen 
tank so you can be more independent. 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% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this drug or 
item is $246.18, resulting in a coinsurance amount of $49.24 ($246.18 x 20% = $49.24). 
 
You have been asked to pay a $49.24 coinsurance for oxygen equipment. This item/service falls within the 
durable medical equipment (DME) and related 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 coinsurance for oxygen equipment provided from June 9, 
2022, to July 9, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility (SNF). 
 
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 was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are stable, and 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. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional eight routine transportation trips. 
 
You asked the Plan to pre-approve an additional eight routine transportation trips. You say that the enrollee 
needs transportation for medical appointments. The Plan denied your request. The Plan says the enrollee has 
utilized 36 of the 40 allowed trips. Additional trips beyond 40 are not covered. 
 
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 40 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 an additional eight routine transportation trips.