Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided 
on June 22, 2022, to June 28, 2022. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you feel it the 
services should fall under home health care. 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 $35 
copayment per visit for outpatient rehabilitation services.  
 
You have been asked to pay a $35 copayment per visit for outpatient rehabilitation services. The total allowed 
amount is $105. However, you are only being asked to pay $102.98 which is less than the required amount. 
This item/service falls within the outpatient rehabilitation 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 outpatient rehabilitation services provided on June 22, 2022, to June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on February 16, 2022. 
 
You asked the Plan to pay for a nursing facility care visit. You say that you are requesting reconsideration for 
the denied claim. 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 a nursing facility care 
visit provided on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that it would be a hardship if the enrollee has to change 
providers. The Plan denied your request. The Plan says the service can be provided by an in-network provider. 
 
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 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two core buildups, including any pins when required 
(D2950 x2), pontic (D6245), and two retainer crowns (D6740 x2). 
 
You asked the Plan to pre-approve the core buildups, pontic, and retainer crowns. You say that you would like 
these services approved for coverage to fix your teeth, help you chew, and to stop biting your cheek. The Plan 
denied your request. The Plan says the requested services 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 two 
core buildups, including any pins when required (D2950 x2), pontic (D6245), and two retainer crowns (D6740 
x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation rides. 
 
You asked the Plan to pre-approve the non-emergency transportation rides. You say that this denial for safe 
ride transportation services for 18 rides should be overturned and approved because you are disabled. The Plan 
denied your request. The Plan says this service is not covered by the Plan. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation rides.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) of the lumbar spine, of 
the cervical spine, and the thoracic spine without contrast. 
 
You asked the Plan to pay for the MRIs. You say that the enrollee still has chronic pain and needs follow up 
imaging done. The Plan denied your request. The Plan says the enrollee did not have signs of impaired nerve, 
spinal cord, or brain function and there were no changes in the enrollee's symptoms; therefore, the MRIs are 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 pay for the MRIs. Our reviewer says that the MRIs 
of the lumbar spine, of the cervical spine, and the thoracic spine is not medically necessary. Our physician 
reviewer found that review of all the enclosed medical records including the additional information tab 
revealed partially illegible handwritten notes going back to February 9, 2022.  It appears the enrollee had 
multiple back surgeries going back to 2010 at what is referred to the "spine center." On the note of February 9, 
2022, the enrollee claims their prior providers, assuming surgeons, "do not want to touch them."  The enrollee 
has had epidural steroid injections unknown sites and timing. Their recent encounters with their primary care 
physician October 3, 2022, March 9, 2022, February 9, 2022, do not include a detailed neuro exam and no plain 
film studies or cross-sectional imaging reports are in the records. The notes describe radiculopathy but no 
specific dermatome or nerve root distribution. A note states the enrollee wants to see a neurologist but has not 
done so yet. The enrollee is on chronic pain meds. There is a non-specific history of pain but no red flag to 
mandate immediate MRI evaluation of the entire spine without a detailed neurological evaluation. 
 
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 MRIs have not been met. Therefore, we decided that the Plan does not have 
to pay for a magnetic resonance imaging (MRI) of the lumbar spine, of the cervical spine, and the thoracic 
spine without contrast.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and an 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve a 
comprehensive oral evaluation (D0150) and an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body, prefabricated 
abutment, abutment supported porcelain fused to metal crown and bone graft at time of implant placement. 
 
You asked the Plan to pre-approve the dental services. You say that you need a dental implant. The Plan denied 
your request. The Plan says these services are not covered by the Plan's 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 pre-approve a 
surgical placement of implant body, prefabricated abutment, abutment supported porcelain fused to metal 
crown and bone graft at time of implant placement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702). 
 
You asked the Plan to pre-approve the powered upper extremity orthosis. You say that this device is medically 
necessary. The Plan denied your request. The Plan says the requested orthosis is experimental and not covered 
for this use. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the powered upper extremity orthosis. 
Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. 
Our physician reviewer found MyoPro is not the standard of care for this patient's multiple sclerosis condition 
or in widespread use for this patient's condition based on scientific evidence. There is insufficient evidence in 
the literature that the MyoPro orthosis will improve the long term outcomes for this patient. 
 
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 powered upper extremity orthosis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a powered upper extremity orthosis (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you cannot do anything by yourself and need 
the bath/shower chair with or without wheels and any size to make easy to take a bath whenever he needed. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ubrelvy tablets. 
 
You asked the Plan to pre-approve Ubrelvy. You say that Ubrelvy is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 Ubrelvy tablets.  
 
Benefits for Ubrelvy 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 October 14, 2021. 
Therefore, we decided that the Plan does not have to pay for the dental services on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gingival irrigation (D4921). 
 
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 
gingival irrigation 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 the 
gingival irrigation (D4921).
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 you suffer from plantar fasciitis, bilateral foot 
deformity and have tried many over the counter shoe inserts as well as heel inserts, and special compression 
socks, that have not been successful. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on September 20, 2022. 
 
You asked the Plan to pay for a nursing facility visit. 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 a nursing facility visit 
provided on September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #11 (D2751). 
 
You asked the Plan to pre-approve a crown. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve a crown on 
tooth #11 (D2751).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist office visit. You say that you are referring the enrollee to a 
provider out of state. The Plan denied your request. The Plan says the service can be provided by an in-network 
provider. 
 
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 
specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on April 01, 2022. 
 
You asked the Plan to pay for a rest home visit. You say that you are requesting reconsideration for the denied 
claim. 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 a rest home visit 
provided on April 01, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) on June 23, 2022. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
Based on this information, we decided that Medicare rules for coverage of magnetic resonance imaging (MRI) 
have not been met. Therefore, we decided that the Plan does not have to pay for magnetic resonance imaging 
(MRI) on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth specialist visit provided on June 25, 2022. 
 
You asked the Plan to pay for a telehealth specialist visit. You say that you see this specific specialist because 
he is the best in his field and you feel the best provider to treat your condition. 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 a telehealth specialist 
visit provided on June 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider. 
 
You asked the Plan to pre-approve physical therapy. You say that physical therapy is needed for the enrollee's 
recovery. The Plan denied your request. The Plan says the enrollee must receive care from a network provider. 
 
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 
physical therapy to be provided by an OON provider.