Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from June 12, 2022, to  
June 18, 2022. 
 
You asked the Plan to pay for inpatient services. You say that you have submitted an itemized bill. The Plan 
denied your request. The Plan says an itemized UB-04 Form was not 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. 
 
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 inpatient services have been met. The file is missing an itemized UB-04 Form. Therefore, we decided that the Plan does not have to pay for inpatient 
services provided from June 12, 2022, to June 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on July 26, 2022. 
 
You asked the Plan to waive the copayment for vision care. You say that you are disputing the share cost. 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 $35 
copayment for vision care.  
 
You have been asked to pay $35 copayment for vision care. This item/service falls within the vision 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 vision care provided on July 26, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional non-emergency mini-bus transportation 
(A0120). 
 
You asked the Plan to pre-approve two additional non-emergency mini-bus transportation (A0120). You say 
that you only have one leg and cannot drive to your doctor's appointments. You also say you need to be able to 
go to your doctor appointments to maintain your quality of life. The Plan denied your request. The Plan says 
per the trip report, you have used 24 trips. The Plan also says that you have zero  trips remaining, and have 
exceeded your benefit limit. 
 
  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 one-way trips, combined in and out-of-network 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 two additional non-emergency mini-bus transportation 
(A0120).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says there is no 
documentation of a recent x-ray or other condition that would require an MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
Based on this information, we decided that Medicare rules for coverage of magnetic resonance imaging (MRI) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance 
imaging (MRI).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lung cancer screening with low dose computed 
tomography (LDCT) scan. 
 
You asked the Plan to pre-approve the LDCT scan. You say that you need to check the stability of the nodules 
on your lungs. The Plan denied your request. The Plan says the enrollee does not meet criteria of being between 
50 - 77 years old; therefore, the LDCT is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
  We looked the file, and Medicare rules. Based on the enrollee being 79 years old and not meeting the age 
requirement of the NCD, we decided that Medicare rules for coverage of the LDCT scan have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a lung cancer screening with low dose 
computed tomography (LDCT) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facial surgery (D7950) provided by a participating 
provider. 
 
You asked the Plan to pre-approve facial surgery. You say that you need to have your wisdom teeth taken out. 
The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
facial surgery (D7950) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of mini implant (D6013 x4). 
 
You asked the Plan to pre-approve the surgical placement of mini implant (D6013 x4). You say that that the 
dentist submitted documentation that the service is medically necessary. The Plan denied your request. The 
Plan says this service is not covered under the benefit package. 
 
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 
surgical placement of mini implant (D6013 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (D6011) and a bone 
graft at time of implant placement (D6104) for tooth #12. 
 
You asked the Plan to pre-approve the dental services. You say that the implant is being requested to aid 
mastication and to avoid migration of upper teeth. The Plan denied your request. The Plan says surgical access 
to an implant body and bone graft at time of implant placement are excluded from coverage. 
 
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 
surgical access to an implant body (D6011) and a bone graft at time of implant placement (D6104) for tooth 
#12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you still have money to use for your 
maximum, so you want to use it towards your dentures. 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. Complete upper denture 
(D5110) but is limited to one every 60 months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested complete upper denture (D5110) was exhausted on date of service March 
9, 2022. Therefore, we decided that the Plan does not have to pre-approve complete upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices provided on March 30, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for pneumatic compression devices. You say that the durable medical equipment is 
medically necessary. The Plan denied your request. The Plan says you submitted an incomplete Physician 
Letter of Medical Necessity form and did not obtain prior authorization prior to using the device. 
 
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 pneumatic compression devices provided on 
March 30, 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 subsequent nursing facility care provided on July 12, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the 
provider failed to submit the claim within the timely filing limits. 
 
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 nursing facility care was not filed until July 16, 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 nursing facility care provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a dental visit. You say that you have seen this dentist for years and just do 
not want to switch to a new dentist. The Plan denied your request. The Plan says the member's needs can be 
met by an in-network provider. The Plan also says that there are 100 in-network dental providers within a 20 
mile radius of the member's zip code. 
 
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 
a dental visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266), alveoloplasty not in 
conjunction with extractions (D7320), vestibuloplasty ridge extension (D7350), and bone replacement graft for 
ridge preservation (D7953). 
 
You asked the Plan to pre-approve guided tissue regeneration (D4266), alveoloplasty not in conjunction with 
extractions (D7320), vestibuloplasty ridge extension (D7350), and bone replacement graft for ridge 
preservation (D7953). You say that if the services are not approved, your dentist says that your work would be 
incomplete. You also say that your quality of life is being affected. The Plan denied your request. The Plan 
says these services are not covered under the member's contract under any normal circumstances. 
 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 
guided tissue regeneration (D4266), alveoloplasty not in conjunction with extractions (D7320), vestibuloplasty 
ridge extension (D7350), and bone replacement graft for ridge preservation (D7953).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit, the scanning computerized 
ophthalmic diagnostic imaging, a gonioscopy, and an ophthalmic ultrasound to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit, the scanning computerized ophthalmic diagnostic 
imaging, a gonioscopy, and an ophthalmic ultrasound. You say that you are having problems with your left eye 
and want to go and see the same doctor that did your cataract surgery on your right eye. The Plan denied your 
request. The Plan says medically necessary care is 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 
a specialist office visit, the scanning computerized ophthalmic diagnostic imaging, a gonioscopy, and an 
ophthalmic ultrasound to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6545 that 
were issued on June 9, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit for the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee had open venous stasis ulcers or a qualifying wound. This means 
that the enrollee did not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pay for the compression stockings identified 
with code A6545 that were issued on June 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa tablets. 
 
You asked the Plan to pre-approve Gemtesa tablets. You say that the enrollee has tried multiple other 
medications with no improvement. You also say that this medication works best for the enrollee. The Plan 
denied your request. The Plan says Gemtesa is a self-administered drug, and does 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 pre-approve Gemtesa tablets.  
 
Benefits for Gemtesa tablets 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your denture, so you need to get it 
replaced. 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. This benefit includes the 
requested mandibular partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5214) but is limited to one time every 60 months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 4, 2022. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture - cast metal 
framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial denture (D5283). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
service. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the partial denture is not covered by the 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 pre-approve a 
partial denture (D5283).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the scaling moderate gingival inflammation (D4346), 
gingival irrigation (D4921), and the medicaments (D9630). 
 
You asked the Plan to pre-approve the dental services. You say that you are in pain, and it is necessary for you 
to get the dental procedures done. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because the scaling moderate gingival inflammation, gingival irrigation, and the 
medicaments are not covered by the 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 pre-approve the 
scaling moderate gingival inflammation (D4346), gingival irrigation (D4921), and the medicaments (D9630).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D3431) provided by a participating provider. 
 
You asked the Plan to pre-approve biologic materials to aid in soft and osseous tissue regeneration. You say 
that you were approved for a root canal, but due to an infection, the root canal cannot be done. The Plan denied 
your request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
biologic materials to aid in soft and osseous tissue regeneration (D3431) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be rendered by the out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are available with an in-network 
provider. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic services to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120) provided by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to pre-approve 
these 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 6, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture 
(D5110 and D5120) provided by a participating provider.