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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 5, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are in pain. You say that your teeth are 
breaking up into the jaw. You say that you need teeth to chew food. You say that the previous dentist you saw 
would not do the procedure for your condition. You also say that you were referred to an oral surgeon. The 
Plan denied your request. The Plan says a comprehensive oral evaluation once every 3 plan years. The Plan 
also says that the frequency limit has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and a comprehensive oral evaluation 
once every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on December 8, 2021. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation (D0150) provided on January 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes 
(99239) provided on February 28, 2021. 
 
You asked the Plan to pay for hospital discharge day management. You say that this service was medically 
necessary and is supported in the medical record. The Plan denied your request. The Plan says this service is 
not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the exact time spent 
providing this service is not noted in the record. Based on this information, we decided that Medicare rules for 
coverage of hospital discharge day management have not been met. Therefore, we decided that the Plan does 
not have to pay for hospital discharge day management; more than 30 minutes (99239) provided on February 
28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 22, 23, 26, and 27, 
and pontics (D6245) for teeth # 24 and 25. 
 
You asked the Plan to pre-approve the fixed bridge. You say that the requested fixed bridge is recommended by 
medical order. You also say that the denture has not been worked on for 20 years or more. The Plan denied 
your request. The Plan says there is significant bone loss. The Plan also says that the requested services are not 
medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the fixed 
bridge when the services are medically necessary and reasonable.  
 
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 fixed bridge. Our reviewer says that 
the criteria have not been met for the requested fixed bridge.  Our physician reviewer found the imaging provided does not support that there is enough supporting bone to allow the requested retainer crowns and pontics. Therefore, the reviewer found that the criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the fixed bridge have not been met. Therefore, we decided that the Plan does 
not have to pre-approve retainer crowns (D6740) for teeth # 22, 23, 26, and 27, and pontics (D6245) for teeth # 
24 and 25.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services for a second opinion to be provided 
by the requested out-of-network provider. 
 
You asked the Plan to pre-approve physician's services for a second opinion to be provided the requested out-
of-network provider. You say that you are dying because of lack of medical treatment from the Plan's 
providers. The Plan denied your request. The Plan says you are contractually required to obtain this service 
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 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 
physician's services for a second opinion to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of residual tooth roots (cutting procedure) 
(D7250), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation 
of mucoperiosteal flap if indicated (D7210), and comprehensive oral evaluation - new or established patient 
(D0150), to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve removal of residual tooth roots, dental extraction and comprehensive oral 
exam. You say that you are in pain and these services are necessary. The Plan denied your request. The Plan 
says dental services are only covered when rendered by a participating provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
The Plan covers one dental extraction and two comprehensive oral exams per year when the services are 
rendered by a participating general dentist. 
 
We looked at the file and Medicare rules. Though the Plan offers dental benefits in excess of Medicare 
coverage, the removal of residual tooth roots is not among those covered services. The services at issue are 
requested to be performed by an oral surgeon. The Plan only covers dental services provided by a participating 
general dentist. Based on this information, we decided that the Plan's rules for coverage of removal of residual 
tooth roots, dental extraction and comprehensive oral exam have not been met. Therefore, we decided that the 
Plan does not have to pre-approve removal of residual tooth roots (cutting procedure) (D7250), extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated (D7210), and comprehensive oral evaluation - new or established patient (D0150), to be 
performed by an oral surgeon.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on March 24, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that a claim for the same procedure (97110) was 
partially paid for a different date of service, February 18, 2021. The Plan denied your request. The Plan says 
this provider is out-of-network with the Plan, and authorization was not obtained prior to the services being 
rendered. The Plan also says that regarding the appellant's statement that the Plan paid for similar services 
rendered on February 18, 2021, they reviewed their records and determined that was due to an administrative 
error. 
 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 therapeutic exercises (97110) provided on March 
24, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech/hearing therapy (92507) provided on May 11, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for speech/hearing therapy. You say that another claim for a different date of 
service, February 5, 2021, for the same procedure code (92507) was partially paid. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to 
the services being rendered. The Plan also says that they reviewed their records and determined that the claim 
for services rendered on February 5, 2021, was denied for no authorization, and the claim was not paid. 
 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 speech/hearing therapy (92507) provided on May 
11, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97710) provided on April 12, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that a claim for a different date of service, 
February 18, 2021, for the same procedure code (97110) was partially paid. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan, and authorization was not obtained prior to the services 
being rendered. The Plan also says that regarding the appellant's statement that the Plan paid for similar 
services rendered on February 18, 2021, they reviewed their records and determined that was due to an 
administrative error.  
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 therapeutic exercises (97710) provided on April 
12, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental services you received on December 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that if you had known you had exhausted your 
benefit, you would have delayed getting these dental services until 2022. The Plan denied your request. The 
Plan says that you exhausted your $2000 annual dental benefit limit, so you are responsible for the full cost of 
these services. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole basis for denial is that you have exhausted your 
$2000 annual dental benefit.  However, the Plan has provided absolutely no documentation proving that you 
have exhausted that benefit.  They have provided no copies of paid claims, Remittance Advices, Explanations 
of Benefits, etc. that may have supported their assertion.  Without such proof, we cannot determine if you have 
exhausted your annual benefit.  The burden is on the Plan to prove why their denial is correct, and it has failed 
to do so here. Therefore, we decided that the Plan has to pay for the dental services you received on December 
15, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Immune Globulin Intravenous (IVIg) therapy. 
 
You asked the Plan to pre-approve the IVIg therapy. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says the IVIG appears to be for rescue 
and not ongoing. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 IVIg therapy.  Our reviewer says that the service is not reasonable or medically necessary. Our physician reviewer found 
IVIG for Immune thrombocytopenic purpura (ITP) is indicated if platelets are less than 30,000. This enrollee 
has a platelet count of 38,000. There is no mention of pending surgeries or procedures. 
 
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 IVIg therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Immune Globulin Intravenous (IVIg) therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on May 17, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises. You say that another claim for a different date of service 
for the same procedure code was partially paid. The Plan denied your request. The Plan says this provider is 
out-of-network with the Plan, and authorization was not obtained prior to the services being rendered. The Plan 
also says that regarding the appellant's statement that the Plan paid for similar services rendered on February 
18, 2021, they reviewed your records and determined that the date of service, February 18, 2021, was paid due 
to an administrative error.  
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 therapeutic exercises (97110) provided on May 
17, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have medical issues 
limiting your ability to sit or stand for an extended period. Your surgeon has given you limits on how much you 
can lift, and you cannot sit in a vehicle or sit for longer than 15 minutes at a time. You also say you would like 
the decision reversed because you are in terrible pain and using public transit does not help you deal with this 
pain. You cannot have restrictions on where you can and cannot go as you have doctors all over WNY and 
rides are longer than 20 minutes. The Plan denied your request. The Plan says additional trips would exceed 
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 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, additional trips will 
exceed your maximum allowed trips per year. Therefore, we decided that the Plan does not have to pre-approve 
additional non-emergent routine transportation trips.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says you can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for atrial fibrillation and pneumonia. Your medical problems are stable, and you have no complex nursing or 
rehabilitation needs. TYou do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There 
is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmological services: medical examination and 
evaluation to be provided by the requested out-of-network provider. 
 
You asked the Plan to pre-approve ophthalmological services: medical examination and evaluation to be 
provided by the requested out-of-network provider. You say that you have had surgery with this provider in the 
past and received great service. The Plan denied your request. The Plan says appropriately qualified specialists 
and 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 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 
ophthalmological services: medical examination and evaluation to be provided by the requested out-of-network 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair, not otherwise classified (K0898). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you had a stroke, has arthritis and 
cannot navigate a regular wheelchair. The Plan denied your request. The Plan says the requested power 
wheelchair is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found on 2/9/22 it is documented that the enrollee is independent with walking. It is noted 
that the enrollee is able to ambulate 50 feet with a walker.  
 This enrollee does not have a personal mobility deficit that impairs participation in MRADLs and the enrollee's 
mobility deficit can be helped by the use of a walker, cane or manual wheelchair. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the power wheelchair, not otherwise classified (K0898).