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

 
We decided that the Plan does not have to pay for dental services provided on August 16, 2022. 
 
You asked the Plan to pay for dental services. You say that this exam was necessary to see if you needed 
surgery. The Plan denied your request. The Plan says the provider opted out of Medicare and is not eligible for 
payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided on August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant (D6010) provided on August 17, 2022. 
 
You asked the Plan to pay for the dental service. You say that the implant was necessary for your bone health. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because implants 
including implant removal, repair, restoration or placement 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 pay for an 
implant (D6010) provided on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided 
January 27, 2022, to February 17, 2022. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that the medical records 
provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the 
requested water circulating heating pad with pump is not considered reasonable and necessary. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heat pad with pump (E0217) provided January 27, 2022, to 
February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and eye imaging provided on August 03, 
2022. 
 
You asked the Plan to pay for the office visit and eye imaging. You say that your records show the provider 
participates with the enrollees Plan. 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 and eye 
imaging provided on August 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your 
request. The Plan says osteoporosis is a contraindication to this type of device. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested device is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
chronic obstructive pulmonary disease (COPD). There is no diagnosis of cystic fibrosis, bronchiectasis, or neuromuscular disease, so the patient does not have a Medicare-coverable diagnosis. This device has not been 
convincingly shown to be beneficial in treating COPD. Also, osteoporosis is a relative contraindication for this 
device. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance non-transport provided on January 19, 2022. 
 
You asked the Plan to pay for ambulance services. You say that you should not be responsible for this bill 
because the police called the ambulance, you did not. The Plan denied your request. The Plan says they do not 
pay for non-transport when an ambulance is called. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 19, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance non-transport provided on January 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) and a periodic oral evaluation (D0120) 
provided on September 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have used this dentist for 10 years. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental 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. 
 
The record shows you received the requested 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 when 
using a non-assigned dentist. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) 
and a periodic oral evaluation (D0120) provided on September 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from October 1, 2021, to October 19, 2021. 
 
You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee exceeded mobility and activities of daily living criteria for a continued stay 
in the skilled nursing facility (SNF).  
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there were no identifiable skilled nursing or skilled therapy services. The 
enrollee did not require skilled nursing or therapy services on a daily basis. The enrollee did not meet severity 
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided to the enrollee from October 1, 2021, to October 19, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye exam provided on July 26, 2022. 
 
You asked the Plan to waive the copayment for eye exam. You say that you should not have to pay this because 
you thought you were getting a yearly contact checkup, instead you were given an eye-glass exam. 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 $40 
copayment for Vision care. 
 
You have been asked to pay a $40 copayment for eye exam. This item/service falls within the Vision care 
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 eye exam provided on July 26, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2751) provided on November 23, 2020, and the 
oral evaluation (D0120) and the prophylaxis (D1110) provided on August 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to refund you for the 
dental services. The Plan denied your request. The Plan says your maximum dental benefit has already been 
exhausted for both dates of services. 
 
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 maximum dental benefit allowance for the year of 2020 was exhausted on the date of service 
September 29, 2020, and your maximum dental benefit allowance for the year of 2021 was exhausted on March 
8, 2021. On January 27, 2020, the Plan paid $89 towards the yearly dental benefits. On September 29, 2020, 
the Plan paid $146 towards the yearly dental benefits making the total the Plan paid for dental benefits in the 
year of 2020 $235 ($89 paid + $146 paid). On March 8, 2021, the Plan paid $750 towards the yearly dental 
benefits. Therefore, we decided that the Plan does not have to pay for the crown (D2751) provided on 
November 23, 2020, and the oral evaluation (D0120) and the prophylaxis (D1110) provided on August 27, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rebasing a complete maxillary denture (D5710) provided on 
July 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are on a fixed income and cannot afford 
additional outstanding accounts. The Plan denied your request. The Plan says rebasing complete maxillary 
dentures (D5710) 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 rebasing a 
complete maxillary denture (D5710) provided on July 28, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from June 4, 2022, 
to June 7, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that the stay was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review has determined that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from June 4, 2022, to June 7, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital care provided on 
August 04, 2022, to August 07, 2022. 
 
You asked the Plan to reduce the copayment for the inpatient hospital care. You say that you feel you were 
charged for an extra day, and you were informed that this would not happen. 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 $1,125 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,125 copayment for the inpatient hospital care. This item/service falls within 
the inpatient hospital care 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.Per the EOC, there is a $375 copayment per day for days 1-5 for inpatient hospital care. 
Your stay lasted 3 days, for a total of $1,125. Therefore, we decided that the Plan does not have to reduce the 
copayment for the inpatient hospital care provided on August 04, 2022, to August 07, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation services from April 26, 2022, to 
May 3, 2022. 
 
You asked the Plan to pay for IRF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says the physician's consultation prior to admission to the hospital lists no conditions which 
would require the skill of physician to attend to the enrollee three times weekly. 
 
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 pay for 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 that the enrollee did not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to have required fifteen hours per week of rehabilitative services 
and regular physician evaluation. The enrollees care needs could have been met at a lower 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 pay for acute inpatient rehabilitation services from April 26, 2022, to May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on March 16, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for the inpatient hospital care. You say that you were hospitalized out of country and 
are requesting reimbursement. The Plan denied your request. The Plan says the records do not clarify if the 
services were urgent or emergent. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
 
  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 inpatient hospital care. Our reviewer 
says that the records do not indicate that the care provided was medically necessary. Our physician reviewer 
found the record provided does not establish the medical necessity and reasonableness, as defined by Medicare 
rules, of the requested service. 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital care provided on March 16, 2022, by an out-of-network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an out-of-network provider 
on July 12, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this provider is in-network. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided by an out-of-
network provider on July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that this was medically necessary. 
The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for 
deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. This is being requested for deep vein thrombosis prevention. Therefore, we decided that the Plan 
does not have to pay for intermittent limb compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 8, 2021. 
 
You asked the Plan to pay for the office visit. You say that the motor vehicle insurance just processed their 
claim on July 13, 2022. The Plan denied your request. The Plan says Medicare denies a claim for untimely 
filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services 
were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the office visit was not filed until July 19, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for an office visit provided on March 8, 2021.