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

 
We decided that the Plan does not have to pay for chest compression system provided on December 23, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chest compression system. You say that you would like to appeal the denial of 
the claim. The Plan denied your request. The Plan says the request was denied as the provider was OON. 
 
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 chest compression system provided on December 
23, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a psychiatric diagnostic evaluation to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the psychiatric diagnostic evaluation. You say that you saw the provider 
requested prior to enrolling into the new insurance and you do not want to run out of your medication waiting 
on a different provider. The Plan denied your request. The Plan says a list of in-network providers that provide 
the same quality of service was given to the enrollee. The in-network providers are accepting new patients and 
can schedule the enrollee within 2 weeks along with providing the enrollee with telehealth appointments. 
 
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 psychiatric diagnostic evaluation 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 a surgical extraction (D7210) and general anesthesia 
(D9222, D9223). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services so that you can get 
dentures. The Plan denied your request. The Plan says these services are not covered by your dental benefit. 
 
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 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 
surgical extraction (D7210) and general anesthesia (D9222, D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9945). 
 
You asked the Plan to pre-approve an occlusal guard. You say that you need the night guard because without it 
your teeth will become more damaged down the line. The Plan denied your request. The Plan says this service 
is not a covered benefit under your dental 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 
occlusal guard (D9945).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connector to 2 power options (E2311). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that please reconsider the documentation 
provided for the wheelchair and accessories that are medically necessary to meet the enrollee's current needs. 
The Plan denied your request. The Plan says the approved power options come with their own switches. There 
is no medical need to control these power options through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head 
array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic 
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an 
attendant control. The enrollee has 2 power options of tilt, and elevating leg rests but the patient does not need 
to control the power options through a joystick. The enrollee's upper extremity strength and function support 
that the enrollee can control any power options through their own switches. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the electronic connector to 2 power options (E2311).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the computed tomography (CT) abdomen, and pelvis, with 
contrast material (74177). 
 
You asked the Plan to pre-approve the CT scan. You say that please reconsider the decision as the imaging is 
necessary and is in the best interest of the enrollee. The Plan denied your request. The Plan says that the 
requested CT scan is not medically necessary as a single detailed picture study should show the doctor all of 
the details needed to treat the enrollee. 
 
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 the CT scan. Our reviewer says that the 
requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer 
found the cerebellar metastatic focus means hematogenous spread of cancer and the enrollee is at high risk for 
metastatic disease elsewhere. Thus, the 6-month CT abdomen and pelvis is reasonable and should be approved 
and the CT chest has already been approved. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve the computed tomography (CT) abdomen, and pelvis, with contrast material (74177).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for teeth # 6 and 11. 
 
You asked the Plan to pre-approve the dental services. You say that your teeth do not match the color of the 
crown that was previously placed. You also say that you need these crowns. The Plan denied your request. The 
Plan says the requested crowns 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 Plans coverage rules apply in this case. The Plan covers the dental 
services 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 dental services. Our reviewer says 
that the crowns are not medically necessary. Our physician reviewer found the provided documentation does not indicate that there is significant coronal breakdown due to caries or fracture of teeth # 6 and 11. Coverage 
for crown restoration is not considered for aesthetic reasons, including color matching. Therefore, the reviewer 
found that the crowns are not medically necessary. 
 
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 dental services have not been met. Specifically, the file does not indicate 
that there is significant breakdown due to caries or fracture. Therefore, we decided that the Plan does not have 
to pre-approve crowns (D2740) for teeth # 6 and 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dentures. You say that you never received the previous dentures, and 
you were told the money was refunded to the previous, non-participating provider. The Plan denied your 
request. The Plan says dentures are covered once every 60 months. You previously received complete dentures 
for both jaws in May of 2021. Therefore, this request exceeds the limitations of your 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. The Plan covers dentures once 
every five years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a 
frequency that exceeds what is covered under this benefit. Documentation supports that the Plan paid for both a 
complete upper and complete lower denture which were provided in May of 2021. Therefore, we decided that 
the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7210), and tooth addition to existing 
partial denture (D5650) to be provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the requested dental services are not covered 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 pre-approve an 
extraction (D7210), and tooth addition to existing partial denture (D5650) to be provided by an out-of-network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive orthodontic treatment of adult 
dentition (D8090), and orthodontic retention (D8680 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you require these services due to lip bites 
and buccal mucosa abrasions per note from your provider. The Plan denied your request. The Plan says 
comprehensive orthodontic treatment of adult dentition and orthodontic retention are not listed as covered 
services. 
 
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 requested comprehensive 
orthodontic treatment of adult dentition and orthodontic retention are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pre-approve a comprehensive orthodontic 
treatment of adult dentition (D8090), and orthodontic retention (D8680 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5211), and a partial 
mandibular denture (D5212) to be provided by a participating provider. 
 
You asked the Plan to pre-approve a partial maxillary denture and a partial mandibular denture. You say that 
you would like the Plan to pay for this. The Plan denied your request. The Plan says these services are not 
covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a partial maxillary 
denture (D5211), and a partial mandibular denture (D5212) to be provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 9, 
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 the place of service is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that the location code must reflect the location in 
which the services were rendered. An exception is when the enrollee is a registered inpatient. In those cases, 
the correct POS code is for inpatient no matter where the services took place. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the outpatient POS code. 
The records support that the enrollee was registered inpatient at this time. Therefore, we decided that the Plan 
does not have to pay for laboratory services provided to the enrollee on November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on November 26, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that it was medically necessary for the enrollee 
to receive the supplies and you would like reconsideration of the denied claim. The Plan denied your request. 
The Plan says the rendering provider is an out-of-network provider and there was no referral from an in-
network provider or an approved authorization. Also, the 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 the wound care supplies provided on November 
26, 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 custom fabricated abutment (D6057) and implant 
supported crown (D6066). 
 
You asked the Plan to pre-approve a custom fabricated abutment and implant supported crown. You say that 
you already have the nail in tooth #12 and now the crown is not approved. You also say that you cannot chew 
with the nail and need the crown. The Plan denied your request. The Plan says these services are 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 a 
custom fabricated abutment (D6057) and implant supported crown (D6066).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from October 
18, 2021, to October 22, 2021, and November 4, 2021, to November 16, 2021. 
 
You asked the Plan to pay for the skilled nursing facility (SNF) care provided from October 18, 2021, to 
October 22, 2021, and November 4, 2021, to November 16, 2021. You say that the services are coverable 
under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive daily skilled 
care on the dates of service in this case. 
 
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 pay for the skilled nursing facility (SNF) care 
provided from October 18, 2021, to October 22, 2021, and November 4, 2021, to November 16, 2021. Our 
reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found 
the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing facility (SNF) care provided from October 18, 2021, to 
October 22, 2021, and November 4, 2021, to November 16, 2021. have not been met. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from October 18, 2021, 
to October 22, 2021, and November 4, 2021, to November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve an upper denture. You say that this service is necessary. The Plan denied 
your request. The Plan says the enrollee previously received a complete upper denture in June of 2018, which 
is less than five years before the current request. The Plan covers one complete upper denture every five plan 
years. 
 
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 can cover one 
complete upper denture (D5110) every five plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the denture is requested in a frequency 
that is not covered under this benefit. Documentation shows that the enrollee received a complete upper denture 
within the last five years, which was covered by the Plan. Therefore, we decided that the Plan does not have to 
pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on March 1, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that these services were urgently needed, and you were 
not able to use a plan provider at the time. The Plan denied your request. The Plan says hearing aids are only 
covered when they are the specific approved models and purchased through the specified hearing vendor. The 
hearing aids in this case were purchased from another vendor, and therefore are not covered. 
 
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 plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when they are the specified premium or advanced hearing aid styles and purchased through 
the Plan's specified routine hearing vendor.  
 
We looked at the file and the Plan's rules. The hearing aids in this case were purchased from a vendor other 
than the one specified by the Plan, and they are not the specific brand required by the Plan. Based on this 
information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we 
decided that the Plan does not have to pay for the hearing aids (V5261) purchased on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment (D8090) and 
orthodontic retention (D8680). 
 
You asked the Plan to pre-approve orthodontic services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental benefit. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive orthodontic treatment (D8090) and orthodontic retention (D8680).