Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve additional routine transportation trips. 
 
You asked the Plan pre-approve the additional routine transportation trips. You say that you need to travel 
more than 50 miles for your pain management treatments. The Plan denied your request. The Plan says your 
benefit only allows 50 miles. This request is not covered by your benefits. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  The Plan covers routine transportation for each one-way trip and it must not exceed 50 miles of driving 
distance. A trip is one-way transportation; a round trip is 2 trips.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incomplete endodontic therapy; inoperable, unrestorable 
or fractured tooth (D3332) provided on July 26, 2022. 
 
You asked the Plan to pay for the incomplete root canal. You say that you are being asked to pay higher than 
the price you were originally quoted. The Plan denied your request. The Plan says this service is not covered 
under your 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 the 
incomplete endodontic therapy; inoperable, unrestorable or fractured tooth (D3332) provided on July 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 28, 2022, to 
July 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 28, 2022, to July 
27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9946). 
 
You asked the Plan to pre-approve the dental service. You say that you thought the dental service would be 
covered under medical. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because the occlusal guard is not covered by the 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 (D9946).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0270) and a periodic oral evaluation 
(D0120) provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was for a normal semi-annual examination. 
This is a normal dental occurrence for proper tooth care. 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 February 8, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewing x-rays (D0270) and a periodic oral 
evaluation (D0120) provided on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on August 16, 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 August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 53 miles in mileage for each one-way trip. 
 
You asked the Plan to pre-approve an additional 53 miles in mileage for each one-way trip. You say that you 
have no other method of transportation to this provider. The Plan denied your request. The Plan says your 
benefit only allows each one-way trip not to exceed 50 miles of driving distance. The Plan also says that this 
request is not covered by your health plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 miles of driving distance each way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 53 miles in mileage for each one-way trip.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 23, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the services should not require 
authorization. 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 laboratory services 
provided on June 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spinal canal 
and contents (72148) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an MRI of the spinal canal and contents. You say that you are ordering an 
MRI for the enrollee to see if the fracture is acute. The Plan denied your request. The Plan says there are 
numerous in-network providers who can accommodate the enrollee, and the enrollee does not have any OON 
benefits. 
 
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 magnetic resonance imaging (MRI) of the spinal canal and contents (72148) 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 pay for emergency dental treatment (D9110) provided on October 
25, 2022. 
 
You asked the Plan to pay for emergency treatment. You say that you do not understand why the procedure is 
not covered because you already started the dental work. The Plan denied your request. The Plan says 
emergency dental treatment (D9110) 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 
emergency dental treatment (D9110) provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral cancer screening, gingival irrigation, and an 
antimicrobial rinse (D4341, D9630, D4921, D0431) provided on August 8, 2022 
 
You asked the Plan to pay for the oral cancer screening, gingival irrigation, and an antimicrobial rinse. You say 
that the services should be covered as you disagree with the denial. The Plan denied your request. The Plan 
says the services denied correctly as they do not fall within 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 oral 
cancer screening, gingival irrigation, and an antimicrobial rinse (D4341, D9630, D4921, D0431) provided on 
August 8, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the ordering physician is responsible for 
obtaining a referral and authorization. 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 laboratory services 
provided on September 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the spine 
without contrast to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary because you might 
need surgery. The Plan denied your request. The Plan says the requested provider is an OON provider and there 
are multiple in-network providers within the enrollee's service area. 
 
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 magnetic resonance imaging (MRI) of the spine without contrast to be provided by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 03, 2022. 
 
You asked the Plan to pay for lab services. You say that this was medically necessary and should be covered. 
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 lab services provided on 
May 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
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 requested item or service was exhausted on date of service September 6, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 test kits provided from August 3, 2022, to 
August 25, 2022. 
 
You asked the Plan to pay for COVID-19 test kits. You say that you have been exposed to COVID-19. The 
Plan denied your request. The Plan says per the CMS, plans or issuers may, but are not required by federal law 
to provide such coverage for over-the-counter at-home COVID-19 tests. The Plan also says that per your 2022 
EOC, if you get services that are not covered, you must pay for the services yourself. 
 
The Plan must follow Medicare rules. Medicare rules say that they will cover up to eight over-the-counter 
COVID-19 tests each calendar month, at no cost to you. Medicare rules also say that enrollees cannot submit a 
claim for these tests to Medicare or their MA plan (unless covered by a supplemental benefit) for 
reimbursement under this initiative.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of COVID-19 test kits have not been met. Therefore, we decided that the Plan does not have to pay 
for COVID-19 test kits provided from August 3, 2022, to August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic maintenance care visits. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the requested services are not a covered benefit by the Plan or by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at this case file and the Medicare rules. Based on this information, we decided that the Medicare 
rules for coverage of these services have not been met. Specifically, the chiropractic maintenance care 
requested in this case is not a covered benefit by the Plan or by Medicare. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic maintenance care visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the foot orthotics are medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis. 
 
You asked the Plan to pre-approve Hymovis. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Orthovisc or Supartz FX. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Hymovis. Our physician reviewer 
found that the enrollee has pain related to osteoarthritis of the left knee. The diagnosis was confirmed with 
imaging studies. She has failed conservative treatment. The Plan requires a trial of Orthovisc or Supartz FX 
before they will approve the requested drug. There is no indication that the enrollee has tried and failed the 
required drugs. There is no indication that the Plan's required drugs would likely be less effective or likely have 
adverse effects for 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 Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core (D2954) provided on May 2, 
2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 a 
prefabricated post and core (D2954) provided on May 2, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6252) for tooth #13. 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 
pontics are not covered by the 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 
pontic (D6252) for tooth #13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve operating room services (D9500). 
 
You asked the Plan to pre-approve the operating room services (D9500). You say that you are going to take a 
dental service but are denying the anesthesia service. The Plan denied your request. The Plan says this service 
is not covered under the benefit package. 
 
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 
operating room services (D9500).