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

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on October 13, 2021. 
 
You asked the Plan to pay for the dental service. You say that you require professional tooth cleaning every 4 
months due to food impactation and gum pocketing. The Plan denied your request. The Plan says 2 cleanings 
are covered per calendar year. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and cleanings are covered, the 
frequency limit of 2 per calendar year has been exceeded. The record shows that the Plan paid for cleanings 
that you received on February 17, 2021, and June 30, 2021. Therefore, we decided that the Plan does not have 
to pay for the prophylaxis (D1110) provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) provided on September 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like reconsideration because you rely on the staff at the facility to verify eligibility. The Plan denied your request. The Plan says prior authorization was not obtained.
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 the domiciliary or rest home visit (99335) provided on September 16, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of the neurostimulator
electrode array (64555) implantable neurostimulator, pulse generator, any type (L8679).
You asked the Plan to pre-approve the electro-acupuncture device. You say that it was determined by the
provider that the enrollee would be an excellent candidate for the PENS (percutaneous electrical nerve
stimulation) unit to help with chronic pain and reduce the use of narcotics. The Plan denied your request. The
Plan says electro-acupuncture devices used for stimulation of auricular acupuncture points is non-covered by
Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the electro-acupuncture device have not been met. Therefore, we decided that the Plan does not
have to pre-approve percutaneous implantation of the neurostimulator electrode array (64555) implantable
neurostimulator, pulse generator, any type (L8679).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950), post and core in addition to a crown (D2954), oral exam (D0120), and complete series x-ray (D0210) provided from August 11, 2021, to August 18, 2021.
You asked the Plan to pay for the core build up, post and core, oral exam, and x-ray. You say that the services should be covered. The Plan denied your request. The Plan says that core build up is not listed as a covered service. The Plan says that post and core in addition to a crown is not listed as a covered service. The Plan also says that the oral exam and complete series x-ray were processed and paid on September 30, 2021.
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, the core build up and post and core in addition to a crown are not among those covered under this benefit. Additionally, the record shows that the oral exam and x-ray you received on August 11, 2021 were reimbursed on September 30, 2021. Therefore, we decided that the Plan does not have to pay for the core build up (D2950), post and core in addition to a crown (D2954), oral exam (D0120), and complete series x-ray (D0210) provided from August 11, 2021, to August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on August 24, 2021, by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for dental services. You say that these services were medically necessary. You say
that you would like the plan to reprocessed and pay this claim. The Plan denied your request. The Plan says
services provided by a non-contracted provider are 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 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 dental services provided on August 24, 2021, by
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
November 2, 2021.
You asked the Plan to pay for the dental service. You say that the previous dentist did not do much for your
dental treatment. You say that you switched dentists. You say that the new dentist did a great job. You also say
that this claim should be paid. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is
covered 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 comprehensive oral evaluation is
listed as covered, the frequency limit of 1 every 3 plan years has been exceeded. The record shows that the Plan
paid for a comprehensive oral evaluation that you received on January 29, 2021. Therefore, we decided that the
Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services. 
 
You asked the Plan to pay for physical therapy services. You say that the physical therapy services are 
medically necessary. The Plan denied your request. The Plan says the physical therapy services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 pay for physical therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is accepted as specific 
and effective therapy for the enrollees condition. The enrollee has had prior physical therapy (PT) and the 
documentation does not reveal why the enrollee requires ongoing skilled therapy. The documentation does not 
reveal that the enrollee requires the unique skills of a professional therapist to safely and effectively provide 
treatment, or that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The enrollee has been educated in a home exercise program. The requested services 
are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified 
therapist is not required to establish, design and/or deliver a program to maintain the enrollees current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on October 12, 2021. 
 
You asked the Plan to pay for the air ambulance services. The Plan denied your request. The Plan says the 
notes show that you could have been taken to the other hospital by other transportation. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  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 pay for the air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary.  Our physician reviewer found that the 
enrollee, on October 12, 2021, presented to the emergency department (ED) with headaches. The evaluation 
with CT scan of the head revealed bilateral subarachnoid hemorrhages. The enrollee was felt to need a higher 
level of care. The enrollee was transferred via air ambulance. The flight team noted the enrollee was alert and 
oriented with stable vital signs and a normal neurological exam. The enrollee requested to walk onto the 
aircraft. The enrollee tolerated transport without any issues. The review indicates that the documentation 
supported that the enrollee suffered from an illness or injury that contraindicates transportation by any means 
other than ambulance. The documentation did not support that the enrollees condition was such that the time 
needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the 
enrollees survival or seriously endangered the enrollees health. The documentation did support that the 
transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided on June 8, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan and the services were 
not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 an office visit (99204) provided on June 8, 2021, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound provided on November 30, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an ultrasound. You say that you cannot attain an authorization you are an invisible provider. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider and there was no referral from the enrollee's primary care physician. Also, the service provided was not urgent or emergent.
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 an ultrasound provided on November 30, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no required skilled nursing services identified. The documentation does not support that it is medically reasonable and necessary to provide skilled therapy services on a daily basis, on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head. 
 
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says a CT scan 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 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 CT scan. Our reviewer says that the 
requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the enrollee is 
a 65-year-old male diagnosed with schizophrenia, anxiety, major depressive disorder, gait abnormality, 
hypertension, and dementia. He has been living in a nursing facility since 2017 for worsening dementia with 
behavioral disturbances and treated with medications and psychotherapy. A head CT scan was requested. There 
was no recent documentation of abrupt worsening of symptoms or findings on examination and this enrollee 
has chronic dementia with known behavioral issues related to this diagnosis. There was no clear explanation in 
the documentation as to why a CT scan is needed at this time or how it would lead to an improved outcome. 
Therefore, this request for a head CT scan will be considered not medically necessary based on the provided 
documentation. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
head.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 3, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your request. The Plan says you declined transport to a health care facility. The Plan also says that this is a non-covered benefit under Medicare and your plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 3, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management; more than 30 
minutes (99239) provided on August 8, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that this service should be paid. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 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 the hospital discharge day management; more than 30 
minutes (99239) provided on August 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient room and board charges provided to the enrollee 
from January 5, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says routine items and services were determined to be inclusive to either room and board, or the 
procedure charge, and are not separately billable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that the routine inpatient services are not supported in the medical record. Specifically, routine 
services of this kind are not to be reported separately. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient room and board charges provided to the 
enrollee from January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 17, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that service was provided to the enrollee so the claim 
should be paid. The Plan denied your request. The Plan says the rendering and referring providers are both out-
of-network providers with no approved authorization. Also, service rendered was not urgent or emergent. 
  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 an office visit provided on August 17, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 26, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that your appointment with a specialist, who was in-
network, was three months away, and after two months your pain and concern of healing gave you no option 
but to seek additional help prior to the specialist appointment. You also say that you went to a doctor that was 
out-of-network, who also was doing routine blood work analysis for you. You also say you were unaware of 
the pre-approval of testing. The Plan denied your request. The Plan says this provider and the referring provider 
are out-of-network with the Plan and the required authorization was not obtained prior to the member receiving 
services. 
 
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 laboratory services provided on July 26, 2021, by 
an out-of-network (OON) provider.