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

 
We decided that the Plan does not have to pre-approve a home ventilator for the enrollee. 
 
You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the ventilator is not indicated for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary. There is documentation that this patient has 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found 
that the enrollee's condition does not meet Medicare criteria for a home ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
periapical radiographic images (D0230) provided on April 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for 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 comprehensive oral evaluation was exhausted on date of service February 15, 2022 
and your benefit for the intraoral periapical radiographic images was exhausted on date of service April 25, 
2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
and intraoral periapical radiographic images (D0230) provided on April 25, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the non-emergency ambulance transportation (A0428) and ground 
mileage (A0425) provided on August 13, 2021. 
 
You asked the Plan to pay for the non-emergency transportation and mileage. You say that this transport should 
be approved, as a discharge to the nursing home is not part of the consolidated billing guidelines. The Plan 
denied your request. The Plan says that these ambulance services are included with payment made to the SNF. 
 
The Plan must follow Medicare rules. Medicare rules say that a medically necessary ambulance trip that 
transports a beneficiary to the SNF for the initial admission may be billed separately.  
 
We looked at the file and Medicare rules. Transportation to the initial admission in an SNF is separately paid 
because it is not included in the SNF consolidated payment. Based on this information, we decided that 
Medicare rules for coverage of the non-emergency transportation and mileage have been met. Therefore, we 
decided that the Plan has to pay for the non-emergency ambulance transportation (A0428) and ground mileage 
(A0425) provided on August 13, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 2, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network, and it was determined these services 
were 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 December 2, 2021, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be rendered 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation. You say that you have been advised by 
medical and dental care providers that your situation requires the services of a prosthodontist. You also say that 
you have found a prosthodontist in your area who assures you that your condition can be successfully 
addressed. The Plan denied your request. The Plan says the service at request is for non-emergency services. 
The Plan also says that this service is not authorized because it would have to be provided by a Plan assigned 
dentist. 
 
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 are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150) to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate mandibular partial denture (D5222). 
 
You asked the Plan to pre-approve an immediate mandibular partial denture. You say that you need dental 
work because you cannot eat. The Plan denied your request. The Plan says this service is not covered under 
your benefit 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 an 
immediate mandibular partial denture (D5222).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the extractions, erupted tooth or 
exposed root (elevation and/or forceps removal) (D7140) and bone replacement graft for ridge preservation - 
per site (D7953) provided January 26, 2022. 
 
You asked the Plan to provide additional payment for the extractions and bone replacement graft. You say that 
these services were necessary. The Plan denied your request. The Plan says the coinsurance for the extractions 
was applied correctly and the bone replacement graft is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the 
extractions with 20% coinsurance.  
 
We looked at the file and Medicare rules. You have been asked to pay 20% coinsurance for the 4 tooth extractions. Though the Plan offers dental benefits in excess of Medicare coverage, the bone replacement graft 
is not among those covered services. Therefore, we decided that the Plan does not have to provide additional 
payment for the extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and 
bone replacement graft for ridge preservation - per site (D7953) provided January 26, 2022.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for lab testing. We decided that the Plan does not have to 
waive the copayment for an inpatient hospital stay.  
 You asked the Plan to waive the copayment for an inpatient hospital stay and lab testing. You say that you 
could not travel home for services because this was an emergency. The Plan says that the copayment applied 
was correct. 
 
We decided that the Plan has to waive the copayment for lab testing.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan says that enrollees cannot be 
asked to pay for lab testing during inpatient hospital care.  
 
The Plan says the enrollee must pay a $40 copayment for lab testing. Based on the plan contract, however, the 
enrollee cannot be asked to pay for lab testing during inpatient hospital care. Therefore, we decided that the 
Plan has to waive the copayment for lab testing.  
 
We also decided that the Plan does not have to waive the copayment for an inpatient hospital stay. 
 
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 $325 
copayment per day for days 1 to 5 of an inpatient hospital stay. You have been asked to pay $1,300 for your 
four-day inpatient hospital stay ($325 copayment x 4). Therefore, we decided that the Plan does not have to 
waive the copayment for an inpatient hospital stay. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy (CPT code 36471 x2) and an echo guide 
for biopsy (76942 x2). 
 
You asked the Plan to pre-approve the services. You say that your left leg has a lot of pain, and it is super 
swollen. You state that your veins feel like they are going to explode, and it needs to be seen and treated. You 
state that you do not know the consequences you can render if you do not get it treated. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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 services. Our physician reviewer 
found the documentation does not meet coverage criteria and does not support the medical necessity of the 
treatments in question. The criteria require an effort at conservative treatment. This has not been satisfactorily 
documented. Additionally, coverage requires that your symptoms be due to the veins slated for treatment. The 
documentation does not support this. The history of present illness from office visit to office visit remains too 
similar to be reliable. Additionally, your symptoms seem to be more suggestive of an arterial process. Even the 
provider had recommended arteriography. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sclerotherapy (CPT code 36471 x2) and an echo guide for biopsy (76942 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup services and the retainer crown services 
received on March 7, 2022. 
 
You asked the Plan to pay for the core buildup services and the retainer crown services. You say that you feel 
these services should be paid. The Plan denied your request. The Plan says the services received 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup services and the retainer crown services received on March 7, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 8 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 8 additional PT visits. You say that the additional visits are medically 
necessary. The Plan denied your request. The Plan says that the requested PT visits 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 pre-approve 8 additional PT visits. Our reviewer 
says that 8 additional PT visits are medically necessary. Our physician reviewer found the requested therapy is 
generally accepted as a specific and effective therapy for the enrollee's condition given the enrollees history. 
The records indicate that the unique skills of a professional therapist are required to provide treatment safely 
and effectively. While the enrollee remains non-ambulatory, they have made slow progress with their ability to 
perform transfers and stand. These skills are important as they transition home from the skilled nursing facility. 
Therefore, the requested additional therapy can be considered medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional PT visits have been met. Therefore, we decided that the Plan has to 
pre-approve 8 additional physical therapy (PT) visits.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for testing provided in a physicians office on 
January 26, 2022. 
 
You asked the Plan to waive the copayment for testing provided in a physicians office. You say that you dont 
know why you must pay for this test it was covered in the past. The Plan denied your request. The Plan says the 
copayment applied is correct. 
 
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 $5 
copayment for services obtained from a primary care provider or under certain circumstances, treatment by a 
nurse practitioner or physicians assistant or other non-physician health care professionals in a primary care 
providers office (as permitted under Medicare rules). 
 
 You have been asked to pay $5 copayment for testing provided in a physicians office. Testing provided in a 
physicians office falls within the Physician/Practitioner Services, Including Doctors 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 testing provided in a physicians 
office on January 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for EKG provided on April 15, 2022. 
 
You asked the Plan to waive the copayment for EKG. You say that you already paid $20 copayment for an 
office visit you shouldn't have to pay more. The Plan denied your request. The Plan says the copayment applied 
is correct. 
 
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 $25 
copayment for Medicare covered non-radiological diagnostic services.  
 
You have been asked to pay $25 copayment for EKG. EKG falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
EKG provided on April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0380) provided on April 21, 2022. 
 
You asked the Plan to pay for imaging. You say that this service was medically necessary. The Plan denied 
your request. The Plan says cone beam imaging (D0380) is not covered by 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 cone 
beam imaging (D0380) provided on April 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed and side rails. 
 
You asked the Plan to pre-approve a total electric hospital bed and side rails. You say that these items are 
medically necessary. The Plan denied your request. The Plan says that a fully electric hospital bed is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed and side rails.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair or modification of hearing aid (V5014), ear 
impression (V5275), and fitting, orientation, checking of hearing aid (V5011) provided from October 19, 2021, 
to December 13, 2021, by the out-of-network provider. 
 
You asked the Plan to pay for the hearing aid services. You say that you are trying to get all of your benefit 
applied to the bill. The Plan denied your request. The Plan says the hearing aids must be purchased through 
Plan Hearing and you must register with them prior to receiving the hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a Plan Hearing network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid services have not been met. Specifically, the provider in this case is not a Plan 
Hearing provider. Therefore, we decided that the Plan does not have to pay for the repair or modification of hearing aid (V5014), ear impression (V5275), and fitting, orientation, checking of hearing aid (V5011) 
provided from October 19, 2021, to December 13, 2021, by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that these compression stockings are 
medically necessary for your condition. The Plan denied your request. The Plan says these items are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.