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

 
We decided that the Plan does not have to pay for the hearing aids provided on January 24, 2023. 
 
You asked the Plan to pay for the hearing aids. You say that the Plan confirmed that you have out-of-network 
benefits for your hearing aids. The Plan denied your request. The Plan says the hearing aids are not covered 
benefits. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only received by a network provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. The record shows the provider was out-of-network. Therefore, 
we decided that the Plan does not have to pay for the hearing aids provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the service dog services. 
 
You asked the Plan to pre-approve  the service dog services. You say that your service dog is your motivation 
to keep going. You say you do not have the funds to provide for her. The Plan denied your request. The Plan 
says the services are not covered benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 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 service dog services have not been met. The record shows your dog is 
considered an emotional support dog and an emotional support dog is not needed to treat illness or injury. 
Therefore, we decided that the Plan does not have to pre-approve  the service dog services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0999) provided on March 7, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the ambulance services have been met. 
No medical records were provided to support the billed service. Therefore, we decided that the Plan does not 
have to pay for ambulance services (A0999) provided on March 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services provided on February 9, 
2021. 
 
You asked the Plan to pay for the ER services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says it has been more that 12-months since the services were rendered. 
 
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 ER services was not filed until February 17, 2023. 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 the emergency room (ER) services provided on February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD that provides intermittent limb compression for 
the purpose of prevention of 
venous thromboembolism (E0676) is a preventive service. Items that are used for a preventative service or 
function are excluded from coverage. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total knee arthroplasty. 
 
You asked the Plan to pre-approve the total knee arthroplasty. You say that the surgery is medically necessary 
due to pain in her knee. The Plan denied your request. The Plan says the total knee arthroplasty is not medically 
necessary. The Plan says the records do not show what conservative therapies were tried and if the knee pain is 
causing functional disability or diminishing ability to perform activities of daily living. 
 
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 total knee arthroplasty. Our 
reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not show a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures. There were no magnetic resonance imaging (MRI) 
studies provided for review, and the x-ray did not corroborate advanced joint disease of the right knee. 
Additionally, the examinations did not corroborate significant functional disability as related to the right knee 
pathology. 
 
 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 total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the total knee arthroplasty.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service February 15, 
2023.   
You asked the Plan to pay for procedure code 99285. You say that this service was medically necessary. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99285 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99285 billed for date of service February 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer purchased on January 13, 2023. 
 
You asked the Plan to pay for the nebulizer. You say that the item was medically necessary. The Plan denied 
your request. The Plan says this item was purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the nebulizer purchased on January 13, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final 
restoration) (D3310). 
 
You asked the Plan to pre-approve the endodontic therapy. You say that you are requesting authorization to go 
to the dentist that your dentist referred you to. The Plan denied your request. The Plan says dental services from 
an out-of-network provider are not covered by your supplemental benefits.  The Plan also says that there are in-
network providers within 20 miles of your zip code. 
 
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 endodontic 
therapy, anterior tooth (excluding final restoration) (D3310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve topical application of fluoride varnish (D1206). 
 
You asked the Plan to pre-approve topical application of fluoride varnish. You say that this should be covered. 
The Plan denied your request. The Plan says this is not a covered service. 
 
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 
topical application of fluoride varnish (D1206).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 17, 2023. 
 
You asked the Plan to pay for dental services. You say that this should be covered. The Plan denied your 
request. The Plan says for this to be covered under the Pick your Perks benefits the claim had to be submitted 
within 120 days since this was after that deadline the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a Pick your Perk benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a Pick your Perk in excess of Medicare coverage, the requested items or services had to 
be submitted within 120 days of the date of service. Since this was received after that deadline the services are 
not covered. Therefore, we decided that the Plan does not have to pay for dental services provided on January 
17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stair lift (A9270) purchased on January 12, 2023.  
 
You asked the Plan to pay for the stair lift. You say that the item was medically necessary. The Plan denied 
your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 pay for the stair lift (A9270) purchased on January 12, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the records do not show that an IRF admission 
is medically necessary.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the abdomen. 
 
You asked the Plan to pre-approve a CT scan of the abdomen. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the requested CT scan is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 pre-approve a CT scan of the abdomen. Our 
reviewer says that the requested imaging is not medically necessary. Our physician reviewer found that the 
medical necessity of the requested CT abdomen has not been established in the records submitted.  No 
ultrasound examination has been performed. 
 
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 CT scan of the abdomen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CT scan of the abdomen.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery provided on April 06, 2023. 
 
You asked the Plan to pay for the cataract surgery. You say that you are requesting reconsideration for the 
denied payment. 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 cataract surgery 
provided on April 06, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on October 
16, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $175 
copayment per day for days 1-5, for inpatient hospital care.  
 
You have been asked to pay a $175 copayment per day for days 1-5, for inpatient hospital care. You are being 
asked to pay $175 per day for days 1-5. The total amount you are being asked to pay is $875 ($175 x 5 days = 
$875). 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. Therefore, we decided that the Plan does not have 
to waive the copayment for inpatient hospital care provided on October 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medial branch nerve blocks. 
 
You asked the Plan to pre-approve the medial branch nerve blocks. The Plan denied your request. The Plan 
says the medial branch nerve blocks 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 medial branch nerve blocks. Our 
reviewer says that the enrollee does not meet the coverage criteria. Our physician reviewer found that there is 
no advanced imaging reviews to determine if there are alternative pain generators. Also, the degree and 
duration of the pain relief is not detailed in the notes. 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 medial branch nerve blocks have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the medial branch nerve blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have a prescription from your 
provider for compression stockings for venous insufficiency. You also say that these stockings are vitally 
necessary for your health. The Plan denied your request. The Plan says the requested item is noncovered under 
the surgical dressing benefit as it does not meet the statutory definition of a dressing. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from January 11, 2023, to 
February 9, 2023. 
 You asked the Plan to pay for home health care. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 11, 2023. The NOA was not received by the Plan until March 7, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health care provided 
from January 11, 2023, to February 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 destruction by neurolytic agent, 
genicular nerve branches including imaging guidance. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve 
ablation is experimental for knee pain. More research is needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, genicular nerve branches including imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, genicular nerve branches including imaging guidance (64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain/ ceramic teeth # 21, #26, #28 
(D6740), pontic- porcelain/ ceramic tooth #23 (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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. Therefore, we decided that the Plan does 
not have to pre-approve retainer crown - porcelain/ ceramic teeth # 21, #26, #28 (D6740), pontic- porcelain/ 
ceramic tooth #23 (D6245).