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

 
We decided that the Plan does not have to pay for the resin-based composites-one surface, anterior  
(D2330 x 2) and the resin-based composites-one surface, posterior (D2391 x 5) provided on August 23, 2022 
and August 25, 2022. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the items provided 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 the benefit for the dental items provided was exhausted on date of service August 23, 2022. Specifically, 
the Plan provides coverage of two restorations (fillings) per calendar year. You previously received two fillings 
on March 3, 2022 and August 23, 2022, that were paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for these items.  Therefore, we decided that the Plan does not have to pay for the resin-based composites-one surface, anterior 
(D2330 x 2) and the resin-based composites-one surface, posterior (D2391 x 5) provided on August 23, 2022 
and August 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that for you to recover fully you need inpatient 
rehabilitation. The Plan denied your request. The Plan says the request is not medically necessary, the services 
you need can be provided safely in other settings, for example, a skilled nursing facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care. 
 
 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Omnipod. 
 
You asked the Plan to pre-approve the Omnipod. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says this drug is self-administered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Omnipod.  
 Benefits for the Omnipod may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transport provided on June 23, 2022. 
 
You asked the Plan to pay for the ambulance transport. You say that you are appealing the denial of the 
ambulance transport. The Plan denied your request. The Plan says that our policy covers non-emergency 
ambulance transportation when it is the only way to safely and adequately transport a member or if other means 
of transporting a member are unsafe due to a medical condition. 
 
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. The Plan did not submit medical records or attempt to obtain medical records, 
without them we cant determine whether ambulance was the only safe way to transport the enrollee, so 
therefore the Plan hasnt shown that their denial on this basis is justified. Therefore, we decided that the Plan 
has to pay for ambulance transport provided on June 23, 2022.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan and a 
computed tomography (CT) scan. 
 
You asked the Plan to pre-approve the PET and CT scans. You say that it is medically necessary that the 
enrollee receive a PET and CT scan. The Plan denied your request. The Plan says the medical records do not 
indicate the enrollee has cancer and that is biopsy proven or strongly suspected in other diagnostic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET and CT scans. Our reviewer 
says that the requirements for coverage for the PET and CT scans have not been met. Our physician reviewer 
found that there were no findings on any prior imaging studies to suggest the presence of a solid tumor in this 
case. Nor were there any findings on physical examination or laboratory testing to readily suggest the presence 
of a malignancy. In as much it cannot be said that the enrollee has a solid tumor "strongly suspected based on 
other diagnostic testing" (and the enrollee does not have one which has been biopsy proven). 
 
  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 PET and CT scans have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan and a computed tomography (CT) 
scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on September 1, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you do not think you should have to pay for these services. The Plan denied your request. The 
Plan says these services are not covered expenses under your dental plan. The Plan also says that you did not 
contact the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on 
September 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 16, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on July 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed (E0302). 
 
You asked the Plan to pre-approve an extra heavy-duty hospital bed (E0302). You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says you did not meet Medicare criteria 
for the requested extra heavy-duty hospital bed (E0302). 
 
The Plan must follow Medicare rules. The rules say an extra heavy-duty hospital bed (E0302) is covered if the 
beneficiary meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds. 
 We looked at the file and Medicare rules. The file shows that your current weight is less than 600 pounds. This 
means that you do not meet criteria for the extra heavy-duty hospital bed you have requested. Therefore, we 
decided that the Plan does not have to pre-approve an extra heavy-duty hospital bed (E0302).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composition - two surfaces, posterior (D2392) 
and resin based composite - four or more surfaces, posterior (D2394) provided on September 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the enrollee never received a handbook on 
dental care. You also say that the enrollee is a stroke victim who is on mental disability as a result, and he is not 
able to pay this claim. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 7, 2022. 
Therefore, we decided that the Plan does not have to pay for a resin-based composition - two surfaces, posterior 
(D2392) and resin based composite - four or more surfaces, posterior (D2394) provided on September 12, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for outpatient surgery provided on June 29, 
2022. 
 
You asked the Plan to reduce the copayment for outpatient surgery. You say that this should only be a $200 
copayment and not $350. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for Outpatient surgery in a hospital outpatient facility. 
 
You have been asked to pay a $350 copayment for outpatient surgery. This item/service falls within the 
Outpatient surgery in a hospital outpatient facility 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 reduce the 
copayment for outpatient surgery provided on June 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on July 
29, 2022. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $330.78 
for colorectal cancer screening. The Plan covers screening colonoscopy every 10 years or 120 months.  
 
You have been asked to pay $330.78 for diagnostic colonoscopy. This item/service falls within the colorectal 
cancer screening 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 diagnostic 
colonoscopy provided on July 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on October 
02, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $220 
copayment for Ambulance services. 
 
You have been asked to pay a $220 copayment for ambulance transport. This item/service falls within the 
Ambulance services 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 ambulance transport 
provided on October 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five custom fabricated abutments (D6057 x5) and five 
abutment supported porcelain/ceramic crowns (D6058 x5). 
 
You asked the Plan to pre-approve the custom fabricated abutments and abutment supported porcelain/ceramic 
crowns. You say that these services are necessary. 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 five 
custom fabricated abutments (D6057 x5) and five abutment supported porcelain/ceramic crowns (D6058 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you need new dentures as someone threw 
yours into a landfill. You also say that you were approved for the bottom dentures but not the top. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 6, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare plans may not offer a massage therapy benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on June 27, 2022, to July 
19, 2022. 
 
You asked the Plan to pay for the mental health services. You say that your PCP changed locations and was 
unable to provide a referral. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the mental health 
services provided on June 27, 2022, to July 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the compression stockings/sleeves identified 
with code A6549 that were issued on April 21, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
  
Although these items may be appropriate, they do 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 issue reimbursement for the 
compression stockings/sleeves identified with code A6549 that were issued on April 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary or rest home visit provided on June 20, 2022. 
 
You asked the Plan to pay for Domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for Domiciliary or rest 
home visit provided on June 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays provided on August 17, 2022. 
 
You asked the Plan to pay for the x-rays. You say that the services were medically necessary. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the x-rays provided on 
August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 14, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 19, 2022. 
 
You asked the Plan to pay for the prophylaxis. You say that you have had gum disease for decades and require 
more frequent cleanings. You also say that you would like this service to be covered because it is preventive. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 27, 2022, and 
May 24, 2022. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided 
on August 19, 2022.