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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and full mouth x-
rays (D0210) provided on July 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. 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 December 18, 2022, and 
November 29, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150), and full mouth x-rays (D0210) provided on July 22, 2022.  The claims for November 29, 2022 and December 29, 2022 were processed prior to July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular monitoring provided on March 15, 2023. 
 
You asked the Plan to pay for the cardiovascular monitoring. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the cardiovascular 
monitoring provided on March 15, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech therapy provided on March 7, 2023, and  March 13, 
2023, by an OON provider.  
 
You asked the Plan to pay for speech therapy. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 speech therapy provided on March 7, 2023, and  
March 13, 2023, by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services received on February 26, 
2023. 
 
You asked the Plan to pay for the hospital discharge services. You say that the services happened in the 
morning before the hospice enrollment. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge services received on February 26, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the  unspecified periodontal procedure, by report (D4999) 
provided on January 12, 2023. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents and unspecified periodontal 
procedure, by report. You say that you are seeking a reimbursement for the service provided. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified 
periodontal procedure, by report (D4999) provided on January 12, 2023.  
 
Your complaint about the customer service experience is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 5, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says an authorization was not obtained prior to 
services rendered. 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 subsequent nursing facility care provided on May 
5, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told by the Plan to go to this 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 on July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the T8 kyphoplasty. 
 
You asked the Plan to pre-approve the T8 kyphoplasty. You say that  the surgery is medically necessary. The 
Plan denied your request. The Plan says the T8 kyphoplasty is not medically necessary. The Plan says the 
enrollee's pain is multifactorial with multilevel disc disease in the thoracic spine and presence of age 
indeterminate compression fracture. 
 
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 T8 kyphoplasty. Our reviewer says 
that the requested service not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for wedge compression fracture of T7/T8 vertebra. The enrollee 
presented with mid-back pain which varies based upon their position. There is pain that radiates around from 
their back and has a known T8 compression fracture.  
 
However, detailed documentation is not evident regarding an acute or subacute compression fracture at T8. The 
imaging studies indicated compression deformity at T8. Additionally, there is no indication of worsening pain, 
a progression of the body height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a 
severe impact on daily activities. Also, there is a magnetic resonance imaging (MRI) corroboration of plausible 
other causes of back pain. Therefore, the enrollee does meet the exclusion criteria and the requested 
kyphoplasty at T8 is not medically reasonable or necessary. 
 
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 T8 kyphoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the T8 kyphoplasty.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drugs provided on March 13, 
2023, to March 17, 2023. 
 
You asked the Plan to pre-approve the self-administered drugs. You say that the services should be covered by 
the Plan. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the self-administered drugs 
provided on March 13, 2023, to March 17, 2023.  
 
Benefits for the self-administered drugs 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 a comprehensive oral evaluation (D0150) provided March 
15, 2023. 
 
You asked the Plan to pay for the dental services. You say that your first dentist did not do a good job. You say 
you went to a new dentist and found out you had a broken tooth and an oral infection. 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 3, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided March 15, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on May 14, 2020, to May 
16, 2023. 
 You asked the Plan to pay for the home health services. You say that the services were unrelated to the 
enrollee's terminal condition. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the home health services provided on May 14, 2020, to May 
16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you lost your denture and need 
your dentures to eat and maintain a healthy lifestyle. The Plan denied your request. The Plan says your benefit 
for the maxillary partial denture 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 maxillary partial denture was exhausted on date of service October 6, 2021. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal 
framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (PT) services. to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the therapy services. You say that the approved facility is too far. The Plan 
denied your request. The Plan says network providers are available to render necessary care. 
 
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 (PT) services. to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the criteria for an 
LTACH admission and will require a multidisciplinary approach to help them manage their multiple medically 
and physically complex issues. You also say an LTACH level of care is beyond what can be expected at an 
alternative level of care. The Plan denied your request. The Plan says  admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating medical necessity for admission to an LTACH. There are no services available at the LTACH that the enrollee requires that are not available at the 
health care setting being offered by the Plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs cannot be adequately 
cared for in their current condition at a skilled nursing facility or any other lower level of care.  The Plan 
denied your request. The Plan says the enrollee does not meet the guidelines for LTACH services.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. The documentation does not support that LTACH services are medically appropriate at 
this time. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the OTC items provided on March 31, 2023. 
 
You asked the Plan to pay more for the OTC items. You say that you were covered by your previous plan at the 
time of the purchase of the items. The Plan denied your request. The Plan says you have exceeded the allowed 
benefit amount. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the OTC items was exhausted on March 31, 2023. The record shows you had a balance 
of $59.01 on your card and your purchase totaled $60.16. The Plan applied the $59.01 towards the benefit, 
leaving the remaining balance of $1.15. Therefore, we decided that the Plan does not have to pay more for the 
over-the-counter OTC items provided on March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on January 3, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that you are having pain and can hardly walk. The 
Plan denied your request. The Plan says bilateral facet joint injections are not medically necessary.   
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 injections. Our reviewer says that 
you do not meet the coverage criteria. Our physician reviewer found that you have low back pain that radiates 
into the right lower extremity. Also, you have radicular pain in additional to axial pain. Additionally, there is 
no imaging report documented. Therefore, the request is not medically reasonable and necessary. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bilateral facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stationary compressed gaseous oxygen system 
(E0424). 
 
You asked the Plan to pre-approve a stationary compressed gaseous oxygen system (E0424). You say that the 
enrollee loses power frequently and must have an oxygen supply reservoir. The Plan denied your request. The 
Plan says the request for oxygen supplies for preventative or precautionary purposes is not covered by 
Medicare or the Plan. The Plan says the enrollee already has an oxygen concentrator and a portable oxygen 
concentrator for use inside the home. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has an oxygen concentrator and a portable oxygen concentrator. An oxygen 
concentrator and a portable oxygen concentrator serves the same purpose as a stationary compressed gaseous 
oxygen system (E0424). Therefore, we decided that the Plan does not have to pre-approve a stationary 
compressed gaseous oxygen system (E0424).