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

 
We decided that the Plan does not have to pre-approve the Special Supplemental Benefits for the Chronically 
Ill (SSBCI). 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one 
of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have 
to pre-approve the Special Supplemental Benefits for the Chronically Ill (SSBCI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on December 1, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that the doctors gave you some tablets to take 
before you were discharged from the hospital. The Plan denied your request. The Plan says self-administered 
drugs do not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on December 1, 2022.  
 Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supplies (A4595) provided on August 8, 2022. 
 
You asked the Plan to pay for the TENS supplies. You say that you would like this claim to be reprocessed. 
The Plan denied your request. The Plan says the order date is missing from the submitted physician 
prescription (order). The Plan also says multiple attempts have been made to obtain the documents, but they 
have not been received. 
 
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. Medicare rules also say that a written order/prescription must include the 
elements listed in the Medicare rules section of this letter. 
 
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 TENS supplies have been met. The 
Plan made multiple attempts requesting medical records, but they were not received. The record also shows 
that the order date is missing from the submitted prescription, which is a required element. Therefore, we 
decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) supplies 
(A4595) provided on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care services provided on August 02, 2022. 
 
You asked the Plan to pay for principal care services. You say that the records attached support the services 
provided. 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 principal care services 
provided on August 02, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an established patient home visit provided on April 22, 2022. 
 
You asked the Plan to pay for an established patient home visit. You say that you are requesting a 
reconsideration for payment. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an established patient home visit provided on April 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scaling and root planing-four or more 
teeth per quadrant (D4341 x 2), gingival irrigation-per quadrant (D4921 x 2), the application of a desensitizing 
medicament (D9910), intraoral-complete series of radiographic images (D0210 x 2), and the comprehensive 
oral evaluation (D0150) provided on December 12, 2022. 
 
You asked the Plan to pay more for the 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. 
 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, gingival irrigation, the application of a desensitizing medicament, and an intraoral-complete 
series of radiographic images are not covered services under the Plans supplemental dental benefit. Therefore, 
we decided that the Plan does not have to pay more for the periodontal scaling and root planing-four or more 
teeth per quadrant (D4341 x 2), gingival irrigation-per quadrant (D4921 x 2), the application of a desensitizing 
medicament (D9910), intraoral-complete series of radiographic images (D0210 x 2), and the comprehensive 
oral evaluation (D0150) provided on December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment and implant supported 
porcelain/ceramic crown (D6056, D6065) provided on August 22, 2022. 
 
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 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 pay for a 
prefabricated abutment and implant supported porcelain/ceramic crown (D6056, D6065) provided on August 
22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection services provided on August 09, 
2022. 
 
You asked the Plan to pay for infectious agent detection services. You say that the records attached support the 
services provided. 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 infectious agent 
detection services provided on August 09, 2022.
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  
(D7140 x 3) provided on October 27, 2022. 
 
You asked the Plan to pay 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 these services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions, 
of an erupted tooth or exposed root (D7140 x 3) provided on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on October 19, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. 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 $40 
copayment for each covered visit or consultation in an outpatient location with a specialist. Covered services 
include consultation, diagnosis, and treatment by a specialist. The provider billed in the amount of $155 and the 
allowed amount is $37.54. This is less than the copayment amount. Therefore, results in the total cost sharing 
amount of $37.54. 
 
 
 
 
 You have been asked to pay a $37.54 copayment, which is less than the copayment for office visit. This 
item/service falls within the physician/practitioner services, including doctor's office visits benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for office visit on October 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve proton beam therapy. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the requested service 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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient prospective, long-term clinical data available to determine 
whether or not proton beam radiation therapy for prostate cancer is superior, inferior, or equivalent to external 
beam radiation therapy, intensity-modulated radiation therapy, or brachytherapy with regards to safety and 
efficacy. Proton beam therapy is not medically reasonable and necessary in this case.  
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 28, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
copaymet. 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 $130 
copayment for ambulance services. 
 
You have been asked to pay a $130 copayment for ambulance services. This item/service 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 services 
provided on June 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on June 12, 2021 and 
June 13, 2021. 
 
You asked the Plan to pay for subsequent hospital care. You say that the patient was not seen in the office and 
was seen only in the hospital and resides in a nursing facility, and it took time to obtain all the necessary 
information needed to be mailed to the Plan. The Plan denied your request. The Plan says the time limit for 
filing has expired. 
 
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 subsequent hospital care was not filed until October 27, 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 subsequent hospital care provided on June 12, 2021 and 
June 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional intraoral x-rays (D0230) provided on October 18, 
2022. 
 
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 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 October 18, 2022. 
Therefore, we decided that the Plan does not have to pay for additional intraoral x-rays (D0230) provided on 
October 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request is not medically necessary, when you are ready to leave the 
hospital, you can safely receive this care in another setting, such as a Skilled Nursing Facility (SNF). 
 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found transfer to the LTACH is not medically necessary as the patient is not yet stable and 
as it would not be clinically advantageous. Completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - three surfaces, posterior (D2393), 
and resin-based composite - four or more surfaces, posterior (D2394) provided on September 22, 2022, and 
September 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have been charged quite a bit more than 
what you were quoted. You also say that the provider should have gotten authorization. The Plan denied your 
request. The Plan says your benefit for the requested items or services $500 dollar limit was met. 
 
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 8, 2022. 
During the processing of these claims, the Plan had previously paid $332 of the maximum allowable for dental 
services. The Plan paid the remaining $168 on the claim for date of service September 22, 2022. This met your 
$500 annual maximum. Therefore, we decided that the Plan does not have to pay for resin-based composite - 
three surfaces, posterior (D2393), and resin-based composite - four or more surfaces, posterior (D2394) 
provided on September 22, 2022, and September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on May 11, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the records attached support the 
services provided. 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 domiciliary or rest home 
visit provided on May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supplies (A4595) provided on September 8, 2022. 
 
You asked the Plan to pay for the TENS supplies. You say that this claim was billed in accordance with the 
enrollee's insurance policy allowable, accepted procedure codes, and diagnosis codes according to plan type. 
The Plan denied your request. The Plan says the documentation submitted did not include a valid physician 
order for the billed date of service/for the billed item(s). 
 
The Plan must follow Medicare rules. Medicare rules say that all claims for DMEPOS items billed to Medicare 
require a written order/prescription from the treating practitioner as a condition for payment. 
 We looked at the file and Medicare rules. Specifically, there is no valid physician order for the billed date of 
service or billed item(s). Based on this information, we decided that Medicare rules for coverage of the TENS 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous 
electrical nerve stimulation (TENS) supplies (A4595) provided on September 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0220, D0230) provided on November 3, 
2022. 
 
You asked the Plan to pay for the dental. 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. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for intraoral x-rays (D0220, D0230) 
provided on November 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PT services to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve PT services. You say that you are requesting PT closer to your home due to 
your back pain and stress. The Plan denied your request. The Plan says requested services are available in-
network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
PT services to be provided by an out-of-network (OON) provider.