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

 
We decided that the Plan does not have to pay for the panoramic x-rays (D0330) provided on July 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you checked with the provider to make sure 
they are in-network and take your insurance. 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 July 14, 2022. Therefore, 
we decided that the Plan does not have to pay for the panoramic x-rays (D0330) provided on July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics (L3000) provided on May 12, 2022. 
 
You asked the Plan to pay 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 under your 
contractual policy or by Medicare for your condition. 
 
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. Additionally, the rules say that with the exception of the situations described above, orthopedic 
footwear billed using code L3000 will be denied as noncovered. Therefore, we decided that the Plan does not 
have to pay for the foot orthotics (L3000) provided on May 12, 2022.
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 the 
pulp vitality tests (D0460) provided on May 12, 2022. 
 You asked the Plan to pay for the dental services. You say that this procedure had to be done or you could have 
gotten very ill. The Plan denied your request. The Plan says these services are either not covered under your 
dental plan or your benefit for the requested item or service has 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 problem focused limited oral evaluation (D0140) was exhausted on dates of service 
February 3, 2022, and March 7, 2022. Additionally, the requested item pulp vitality tests (D0460) 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 the pulp vitality tests (D0460) provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve core build up on tooth #31 (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that the provider told you that the core build up 
needs to be replaced. The Plan denied your request. The Plan says that your benefit for the requested item or 
service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve core build up on tooth #31 (D2950).  
 
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: 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 you are requesting inpatient rehabilitation services so 
you can return safely to your prior level of function. The Plan denied your request. The Plan says your needs 
can be met at a lower level of care such as skilled nursing facility (SNF) or home with home health services. 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  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: 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 this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the criteria for admission to the Acute Inpatient Rehabilitation setting have 
not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
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 the enrollees 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and electrocardiogram provided on March 11, 
2022, by an OON provider. 
 
You asked the Plan to pay for the office visit and electrocardiogram. The Plan denied your request. The Plan 
says the out-of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit and electrocardiogram provided on 
March 11, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), chiropractic manipulative treatment 
(98941), and the mechanical traction therapy (97012) rendered by the out-of-network (OON) provider on  
May 4, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services were rendered by an out-of-
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services.  Therefore, we decided that the Plan does not have to pay for the office visit (99213), chiropractic manipulative 
treatment (98941), and the mechanical traction therapy (97012) rendered by the out-of-network (OON) 
provider on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
June 21, 2022. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you told the treating 
provider not to perform any services that would not be covered. The Plan denied your request. The Plan says 
your benefit for the requested 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 service was exhausted on date of service October 17, 2019. Therefore, we 
decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on June 
21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on April 22, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you cannot afford this 
copayment, it will cause a financial hardship. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for an ambulance ride. 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 an ambulance ride 
provided on April 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 1, 2022, to 
February 15, 2022. 
 
You asked the Plan to pay for the home health services. You say that you were not aware the enrollee's plan 
required a Notice of Admission (NOA) for the final home health claim. You say that the NOA was billed after 
the final claim was billed. You also say that this should be processed as in-network. The Plan denied your 
request. The Plan says  
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a Notice of Admission (NOA) within 5 calendar days after the start of care date for initial 30-day periods and 
within 5 calendar days after the from date for each subsequent 30-day period of care, which is set at 0 percent 
at the beginning of every 30-day period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the NOA was not submitted within 5 days of the from the start of care date, February 1, 2022. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from February 1, 2022, to February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by an 
out-of-network provider on June 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were referred to this specialist by your 
dentist. 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 under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150) provided by an out-of-network provider on June 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit provided on 
June 27, 2022. 
 
You asked the Plan to waive the copayment for the emergency room (ER) visit. You say that you feel the 
facility should be considered urgent care instead of ER. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room (ER) visit. This item/service falls within 
the emergency 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 the emergency room 
(ER) visit provided on June 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
December 15, 2021, to December 24, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that this should be a covered 
therapy benefit. 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 $350 
copayment per day for days 1 to 5 for inpatient hospital care.  
 
You have been asked to pay a $350 copayment per day for days 1 to 5 and $0 for additional hospital days for 
inpatient hospital care. You are being charged $350 for 5 days which equals to $1750; however, you are being 
charged $661.82 which is less than required amount. 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 
inpatient hospital care provided from December 15, 2021, to December 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone grafts for ridge preservation (D7953) provided on 
March 30, 2022. 
 
You asked the Plan to pay for the bone grafts. You say that these services were medically necessary. The Plan 
denied your request. The Plan says bone grafts for ridge preservation (D7953) are 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 bone 
grafts for ridge preservation (D7953) provided on March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external upper-limb tremor stimulator (K1018) and 
supplies (K1019). 
 
You asked the Plan to pre-approve an upper-limb stimulator and supplies. You say that the requested items are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items are 
experimental/investigational. 
 
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 an upper-limb stimulator and supplies. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that although some medical literature reports utility of devices such as the one 
requested in this case for treatment of "refractory" essential tremor, the device is still under study with regard to 
its effectiveness and health economic outcomes. In addition, the provided records do not document evaluation 
and reduction of exacerbating factors such as caffeine usage or trial and failure (or contraindication) of first line 
pharmacotherapy for the enrollee's essential tremor. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an upper-limb stimulator and supplies have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an external upper-limb tremor stimulator (K1018) and 
supplies (K1019).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional 
intraoral periapical x-ray (D0230) provided on June 22, 2022. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that you believe these services are 
covered under your plan. The Plan denied your request. The Plan says these services are not covered benefits 
under your dental plan. The Plan also says that you are not enrolled in the dental rider offered 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 the first 
intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310), and extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) provided on July 5, 2022. 
 
You asked the Plan to pay for a consultation - diagnostic service provided by dentist or physician other than 
requesting dentist or physician (D9310), and extraction, erupted tooth or exposed root (elevation and/or forceps 
removal) (D7140). You say that you do not agree with the denial as this was an emergency service rendered. 
 The Plan denied your request. The Plan says these services are 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 pay for a 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310), and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on 
July 5, 2022.